Repeal Fever is Back on Capitol Hill and It’s Deadly Serious

By Jill Zorn

The Republican majority is feverishly working to pass the Cassidy-Graham bill and take health care away from 32 million people.  They just might succeed.

About the Bill

Cassidy-Graham uses block grants, beginning in 2020, to kill the Affordable Care Act (ACA) marketplaces and Medicaid expansion.  On top of that, the bill institutes per capita caps on the rest of Medicaid, draining financial support for this vital program that serves 70 million Americans.  Over time, these payment mechanisms will not keep up with medical inflation and drain federal funding from the states.  In 2027, this funding disappears all together.

The Center on Budget and Policy Priorities (CBPP) estimates that the bill means $80 billion cut by 2026.  After 2026 the picture gets even worse.  Support for the ACA subsidies and Medicaid expansion completely disappear and the funding dives off a cliff, becoming a $300 billion cut.  These dollars would then be available to allow Republicans to give even bigger tax cuts to “millionaires and billionaires”.

Like many of the other repeal bills, Cassidy-Graham would allow states to apply for waivers that would threaten hard-earned protections, including for people with pre-existing conditions.

But Wait, There’s More

There are three particularly insidious features of this bill that make it even worse than previous versions of repeal.

  1. The block grant funding, which is taken from the ACA subsidies and Medicaid expansion dollars, doesn’t actually have to be spent on retaining the insurance marketplaces and the Medicaid expansion. Instead, states have the “flexibility” to spend the money on other options such as setting up high risk pools.   Remember how well high risk pools worked prior to the ACA?  Hint:  not well!

Even if a progressive state chooses to use the funds for good rather than evil, the decrease in funding over time and its complete disappearance after 2026 does not bode well for positive coverage experiments and expansions.

  1. The second major outrage of this bill is that the block grants will be redistributed. Many red states that failed to expand Medicaid will be rewarded with funding increases, while states that expanded Medicaid will see more draconian cuts.

The map, below, shows which states are winners and which are losers under Cassidy-Graham by 2026. Connecticut, which right now cannot figure out how to close a large budget deficit, will lose over $2.3 billion by 2026 – a cut we can ill afford.  The state-by-state estimates for 2027, when the block grant disappears can be found here.  They are even more dire and show Connecticut’s loss to be over $4 billion. By the way, our entire 2017 state budget was $20.4 billion.

MAP.png

  1. The third despicable aspect of this bill is that it has upped the ante on attacks on women’s reproductive health. In addition to the “familiar” abortion restrictions it bans abortion coverage in any program that receives block grant money.  A state like Connecticut, for example, where abortions are covered by Medicaid, would no longer be permitted to cover this service.

How it Could Pass

This headline says it all:  Rushed Senate Consideration of Cassidy-Graham Would be Designed to Hide Bill’s Severe Flaws.  Why the rush?  The Senate must pass Cassidy-Graham by September 30.  After that, the opportunity to use the budget reconciliation process to pass the bill with a simple majority will be gone.

Word is that the Republicans are close to having the 50 votes they need to pass the bill in the Senate.  If they have the votes, this is how they plan to ram it through the Senate next week:

  • Two rushed hearings have now been scheduled, including one in the Homeland Security Committee – not a committee that normally deals with health care – to provide a fig leaf of “regular order” that may just satisfy Senator John McCain.
  • The vote will be taken with only a preliminary score from the Congressional Budget Office (CBO).   There is not enough time for the CBO to calculate detailed estimates of the impact of the bill on insurance coverage, deficit reduction and insurance premiums will be missing.
  • While the Democrats can try slowing down the business of the Senate, if Mitch McConnell decides to bring it to the floor, that will mean he has the votes and the bill can’t be stopped. Once on the floor, there is nothing to prevent McConnell from calling for a vote after “just two minutes of debate or less”.

If passed by the Senate, the bill would go over to the House.  Their vote would be not subject to the September 30 deadline.  But they would have to pass the bill with no changes.

What Can We Do?

Activists are sounding the alarm and mobilizing for a full-court press against Cassidy-Graham. A rally was held today outside the Capitol in DC and more are planned for next week.  People in states with target Senators have been urged to call and call again, asking their Senator to vote no.

Here in Connecticut, Senator Blumenthal is holding a rally to protect the ACA and Medicaid from this terrible bill at the Legislative Office Building in Hartford on Wednesday, September 20 at 1:30 pm.  Check the Protect Our Care Connecticut web site for information about this and other planned events and sign up to receive action alerts as more are scheduled.

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The latest on Access Health CT

By Rosana Garcia

AHCT 9-14-2017 Board Meeting CT-NWith deadlines fast approaching there has been a recent flurry of activity at Access Health CT.

  • After weeks of uncertainly, we finally learned that there are still two carriers offering coverage through Access Health CT: Anthem and ConnectiCare
  • Open Enrollment is November 1 to December 22, 2017, which extends the original Open Enrollment period by one week
  • Access Health CT selected 10 cities for in-person enrollment locations. Final locations will be announced soon.
  • Insurance premium rates are now set: On September 13 the Connecticut Insurance Department released rates for the individual and small group markets, both on and off exchange (Click here for the 2018 rate chart)
    • Anthem will have an average 31.7% increase for their Access Health CT plans
    • ConnectiCare will have an average 27.7% increase for their AHCT plans

What’s up with the insurance premium rates?

First – if you get help paying your insurance premiums through Access Health CT, you will not see a major increase to your monthly premium!

If you are getting a subsidy (known as an Advance Premium Tax Credit, or APTC), the way the subsidy works is that you only pay a certain percentage of your income in insurance premiums.  This means that you may not feel the major rate increase – depending on which plan you choose.  Find in-person assistance to help you make the best choice for you, or call AHCT’s call center.  Click here to find out how to contact help.

Now let’s get to why insurance premium increases are so high…

There’s been a lot of debate around whether or not the federal government would continue to make cost sharing reduction payments to insurers.  The “will they, won’t they” pay back and forth has made for a lot of uncertainty in the market.  Uncertainty for insurance markets is a four letter word – and has made for the much-discussed market instability.

The federal government could always commit to making these payments for the 2018 year, but so far they are making month-to-month decisions about the payments.

This week, the Connecticut Insurance Department decided to approve insurance premium rates that assume that the federal government will not pay cost sharing reduction payments.  According to Paul Lombardo, staff at the Insurance Department, without these payments, insurance premium rates go up an additional 16.7% on average.

So what happens if the federal government DOES make the payments?

Insurance Commissioner Katherine Wade said that if the federal government does make the payments, she will seek the authority to lower premium rates.

But wait, there’s more…

To dig a little deeper on what happened at the Access Health CT Board Meeting on September 14, click here for the agenda, and here’s the meeting presentation.  Plus, CT-N recorded it and you can watch the meeting here.

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After the Storms…

By Jill Zorn and Stephanye R. Clarke

Deep blue sea at day.

Texas highways and communities were completely submerged under water. The images from Hurricane Harvey will forever be seared into our memory—the same way many of us continue to be haunted by images of Hurricane Katrina.

With Irma now wreaking havoc in Florida and climate change assuring we will have more frequent violent storms, what do we know so far about the impact of Harvey on health and public health?  And how do people’s varying circumstances affect their ability to recover?

Health Care Challenges

Tending to the immediate health care needs of those with chronic and acute illness during and right after Harvey was extremely challenging.  Some hospitals and nursing homes had to be evacuated or faced shortages of staff, medications and food.  Individuals reliant on home care could not receive services in their flooded homes.  Prescription medication was lost in the flood waters and not easily replaced.

Public and Environmental Health

This article lists a wide variety of public health impacts including

  • Drinking water contamination
  • Overflowing sewage from damaged waste treatment plants and failing sewer pipes
  • More opportunities for mosquito-borne illness like Zika to fester and spread
  • Mold and mildew leading to respiratory illness

But it is environmental contamination that may pose an even greater and more long-term threat.  The Houston area is home to a huge chemical industry and regulation of that industry is lax, to say the least.

More than a dozen toxic superfund sites were flooded.   The New York Times reported that one land owner found deposits of highly poisonous mercury on his property.  One chemical plant had multiple explosions, and first responders protecting the perimeter of the plant were overcome by fumes.  Concerns about exposure to benzene and other petrochemicals run high.

Going forward, as this Houston Chronicle article points out, there is insufficient government oversight to protect area residents and to monitor the impact of the toxic stew of chemicals that have been released into the environment.  Many health and safety issues will continue to emerge as chemical plants start up again.

Mental Health

When it comes to mental health care, a natural disaster of this proportion has both short term and long term implications.  Many of us watched, heartbroken, as faces from Texas, the Caribbean and Florida displayed stress, sadness, fear, and hopelessness.  From the outside, seeing the physical damage Harvey created is overwhelming. Irma has shattered life in the Caribbean, is devastating Florida and has her sights sets on Georgia—Jose isn’t far behind her. We cannot imagine the horror of living through either of these storms—the toll the immediate stress can take is unimaginable. We were happy to read that some shelters offer mental health services on-site—this is wonderful for those who are aware of their need for these services.

However, there are many who are dealing with far more than the stress these storms can generate—many have diagnosed mental health issues. Were they able to retrieve their medications before being forced out of their homes by unrelenting storms? Are there enough mental services available in these temporary shelters to serve the people?

A Washington Post article points out the need for the availability of a continuum of mental health services for traumatized and displaced residents, some of whom were displaced by previous storms like Katrina. Any planning to address rebuilding communities must include comprehensive, long-term, quality, affordable and accessible mental health services.

Health Equity

Harvey and Irma’s paths of destruction didn’t discriminate, devastating areas where wealthier residents lived as well as areas where of great poverty.  Low income communities and communities of color experienced some of the worst impacts and will face greater struggles to recover.  Cleanup has begun—there is a long road ahead and rebuilding will take several years.

It is our hope that while federal, state and private funds pour in to areas in the paths of these storms, leadership finds ways to engage community members in the rebuilding/redesign of neighborhoods. This is an opportunity for decision-makers and leaders to ensure that resources flow equitably to those most in need and planning actively engages the communities most impacted.  The storms were a disaster – now it is time to take this moment to not only rebuild, but to build better.  We exhort leaders to be thoughtful and strategic in their plans – and to truly work with people and communities.

We need not repeat the same injustices from the past.

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Getting to Single Payer, Part IV

Federal vs State Strategies

By Jill Zorn

chess-pawn-social-mobilityDespite the political challenges, when it comes to universal health care, all policy roads lead to a federal solution.

What about the Laboratory of the States?

In the United States, the states have always been seen as laboratories for trying out big ideas.  For example, the Affordable Care Act (ACA) approach to health insurance coverage was piloted in Massachusetts.

The Canadian single payer system started in one province, Saskatchewan.  It spread to several more provinces and then was adopted as a national program.

But when it comes to covering everyone, I don’t believe that state-based single payer is the way to go.

Financial and Legal Hurdles to State-Based Single Payer

States face huge financing and legal obstacles.  These include:

  • The ability to raise taxes sufficiently to cover the cost of bringing in thousands of workers currently insured by their employers, when working from a much smaller tax base than the federal government has. It was the taxes, more than anything else, that killed Vermont’s single payer
  • The size of state budgets. The Vermont state budget would have doubled, and similar predictions have been made for California.
  • The need, generally, for states to balance their budgets, which gives them much less flexibility if they have a “bad” health care year. The federal government is in a much better position to absorb the financial hits of an epidemic, or a new expensive drug, than are state governments.
  • The federal government has more bargaining power than any given state to keep health care prices under control — as long as it chooses to use that power.
  • A pesky law called ERISA, which allows larger employers to “self-insure”. Self-insured companies can only be regulated by the federal government.  In Connecticut, most people with insurance work for companies that self-insure.  That means the state government has no ability to regulate how they get their insurance.  During the passage of the ACA, ERISA was modified to make sure that most new health insurance rules, like eliminating life time and annual limits, applied to all plans.  But the chances of opening up ERISA to accommodate a few states who want to go to single payer don’t look very promising.  Blogger Jon Walker refers to ERISA as “the 900-pound-gorilla standing in the way of state-based reform.”

Federal Government Resources

By one measure, government’s share of health spending is already close to two-thirds of all national health expenditures and the federal government is already funding the lion’s share of these costs.  This includes Medicare, tax subsidies for employers, ACA subsidies, federal employee health benefits, direct coverage provided by the Indian Health Service and for veterans and active military members, and at least half of states’ Medicaid budgets.

The federal government is already funding and setting standards for a huge portion of our health care.  They have the size, the organizational expertise and experience, the authority and the ability to raise the revenues to finish the job.  That’s not to say it will be easy, but it is certainly doable.

Politics

While the policy challenges for figuring out how to get to universal health care at the federal level are enormous, the political challenges are even bigger.  Some of these hurdles are discussed in the first two blogs in our single payer series.  Nationally, it is politics, not policy that is keeping us from moving forward.

Because the political challenges are so strong at the federal level, there is a natural tendency to look again at whether single payer is possible at the state level.

There may be a handful of states that have the potential to overcome the politics.  If any state is going to do it, it is a wealthy, solidly left-of-center state like California.  But so far they have not succeeded.  The cold hard reality is that the policy barriers may be too steep to overcome at the state level, even if the political will is there.

Connecticut

Here in Connecticut, we are struggling to close a $3 billion budget deficit and have started the new fiscal year without agreement on the budget for this year and next.  Even if the policy challenges listed above where not there, we are far from being in the fiscal shape or building the political consensus in the “insurance capital of the world” necessary to take on crafting and implementing a single payer bill.

But that doesn’t mean that supporters of single payer should just sit back and wait for federal action following the 2020 election.   As we know, election results are very unpredictable.

The next two blogs in the series will look at possible policies to focus on at both the federal and state level to move us closer to universal health care.

To learn more:

Road to Single-Payer: Overcoming Hurdles at the State Level, by Jon Walker, Shadowproof

Vermont Single Payer: What Went Wrong? by Jill Zorn

What Killed Single-Payer in California? by Clio Change, New Republic

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Federal health care proposals – learn more ahead of Congress returning from recess

Stethoscope-HealthCareWhile the health care debate has taken a step back from the national stage, there are still proposals being developed and discussed.  Some proposals coming out at the federal level are bipartisan, while others ride the party line.

Here’s a quick rundown of some of those proposals, and where to learn more.

Cassidy-Graham (Repeal & Replace)

The Cassidy Graham proposal is essentially a repeal and replace attempt, put together by Republican Senators Bill Cassidy (Louisiana) and Lindsey Graham (South Carolina).  It radically restructures Medicaid funding to states, through major cuts.  It also appears to favor states that did not expand Medicaid, and harm those who did expand, like Connecticut.

Learn more: The last GOP health plan left standing, explained (Vox, Sarah Kliff, 8/1/2017)

What effect would this plan have on Connecticut?  The Center on Budget and Policy Priorities analyzed the plan and how it would impact different states.  See this article in the CT Mirror for more on state-level impact: Obamacare replacement plan would hurt CT, report says (Ana Radelat, 8/24/17)

Rep. Conyers Single Payer Bill (HR 676)

Democratic Representative John Conyers (Michigan) has put forth a single-payer proposal – meaning that everyone in the country would be covered by one government insurer.  117 House Democrats have signed onto the bill, and the expectation is that Senator Bernie Sanders (Vermont) will be putting forth a Senate version when Congress comes back from recess next week.

What Rep. John Conyers’s sweeping single-payer health care bill would actually do (Vox, Jeff Stein, 8/28/17)

Interested in taking a deeper dive into single payer?  Check out our “Single Payer” Series.

Problem Solvers Caucus

In a bi-partisan effort, Republican and Democratic members of the House have presented a package of five strategies aimed at stabilizing the individual market:

  1. Continuing cost sharing reduction payments that help reduce out of pocket costs for low income on-exchange members
  2. Creating a stability fund to help states lower premiums by giving insurers extra funding
  3. Exempting businesses with less than 500 employees from the employer mandate – currently businesses with more than 50 employees are required to provide coverage
  4. Repealing the medical device tax
  5. Allowing insurers to sell plans across state lines

Learn more: The new bipartisan House proposal to fix Obamacare, explained (Vox, Jeff Stein, 7/31/17)

Another opinion: Solving the Problem of Bipartisan Health Care Reform (Health Affairs Blog, Robert Pozen, 8/22/17)

Medicare Buy-In

Our own Connecticut Representatives, John Larson and Joe Courtney joined New York Rep. Brian Higgins in putting forth the Medicare Buy-In and Health Care Stabilization Act.  The proposal would allow adults ages 50 to 64 to buy into the Medicare program on the exchanges.  The Medicare Buy-In option would also be available to employers who provide coverage for their employees.

You can read more about this plan in Reps. Larson and Courtney’s own words: Larson, Courtney: Fix ACA by letting 50 to 64-year-olds join Medicare (CT Mirror Viewpoints, 8/22/17)

Medicaid Buy-In

Hawaii’s Democratic Senator Brain Schatz is preparing a bill that would allow for a Medicaid Buy-In on the state exchanges.  This plan targets uninsured people buying insurance on the state exchanges, and would allow people to use the existing subsidies to pay for premiums.  If someone makes too high of an income to qualify for Medicaid, they would pay a premium to be a part of the Medicaid program.

Learn more: Senator Schatz’s new health care idea could be the Democratic Party’s future (Vox, Sarah Kliff & Jeff Stein, 8/22/17)

Expecting new proposals

Next week, as Congress returns after their recess, even more proposals are expected.  As noted above, Senator Bernie Sanders is likely to introduce a single-payer bill in the Senate.

The Senate HELP (Health, Education, Labor & Pensions) Committee is conducting hearings on stabilizing the health insurance market – so proposals are likely to emerge from that process.

A bipartisan plan from two governors – Colorado’s Democratic Governor John Hickenlooper and Ohio’s Republican Governor John Kasich – should be released soon, too.

As always, we will keep you in the loop!

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A Quiet, But Important Step for Consumers – Legislation in Action

By Rosana Garcia

report clip artWith little fanfare, an important report was released from the state: Cost & Market Impact Review of the Hartford HealthCare’s Proposed Affiliation with the Charlotte Hungerford Hospital.

That’s quite a mouthful, but what it really means is that Connecticut is doing its job of watching out for residents in the quickly changing health care landscape of the state.

What’s the big deal?

This is the first of these types of reports, which are meant to take a closer look at the potential impact of a hospital being bought by a large hospital system or for-profit company.

Why does hospital consolidation matter?  Because it can make care more costly and affect access to certain health care services, as larger and larger hospital systems gain more negotiation power.

In Connecticut, if a hospital is being sold, the deal has to be approved by the Office of Health Care Access (OHCA), through the Certificate of Need program.  We have often spoken up at Certificate of Need hearings to make sure that the hospital is accountable to the community it serves.

Now there is an added requirement for OHCA to approve a hospital sale, if the buyer is a large hospital system or a for-profit company – the Cost & Market Impact Review.

The report – more of an analysis – takes a deep dive into looking at four important aspects of this type of deal:

  • Costs and market
  • Access and availability of services
  • Quality and care delivery
  • Consumer concerns

The overall point is to make sure that there won’t be negative effects for the community on health care cost and access from the hospital sale – that’s the big deal about this report.

A little history

Two years ago, the Connecticut state legislature passed Public Act 15-146, which addressed a wide variety of health care issues – including hospital consolidation.  Senators Looney and Fasano were concerned about hospital consolidation, and the ill effects it could have on the people of the state.

To learn more about what was in that law, check out this 2015 blog.

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Getting to Single Payer, Part III

What Do We Mean When We Say “Single Payer”?

By Jill Zorn

chess-pawn-social-mobilityI probably should have started the Single Payer series with this post.  That’s because “single payer” means different things to different people.

 

Policy Prescription or Goal?

 Goal

To some supporters, single payer is a goal.  I have seen that goal or principle described many different ways:

These phrases are about what we aspire to, what we value.  They don’t describe a policy for getting there.

Many articles that use the term single payer to mean a goal often point out that other countries that guarantee coverage and care to their residents have gone about it in different ways.

Jonathan Oberlander summarizes these differences in this New England Journal of Medicine article:

U.S. observers often mistakenly lump all foreign health systems together under the single-payer label — a classification that grossly oversimplifies the range of models in place elsewhere. In some rich democracies (Germany, the Netherlands, and Switzerland among them) people enroll in multiple insurance plans, which are typically highly regulated and are operated by private companies or nonprofit associations…Most U.S. single-payer advocates instead have in mind emulating Canada, where all legal residents in each province or territory receive coverage from one government insurance plan for medically necessary hospital and physician services.

A Specific Policy

To others, single payer is a term that means more than the goal of access to good, affordable coverage and care. Instead, it is a literal description of how that coverage should be structured:

Physicians for a National Health Program (PNHP)Single-payer national health insurance, also known as “Medicare for all,” is a system in which a single public or quasi-public agency organizes health care financing…The program would…(replace) today’s inefficient, profit-oriented, multiple insurance payers with a single streamlined, nonprofit, public payer…

As noted in this quote, there is also a movement toward using the terms “single payer” and “Medicare for all” interchangeably.

The Bernie Sanders campaign popularized the term “Medicare for all“, while defining that term to mean: “a federally administered single-payer health care program.” Healthcare-Now! also uses “single payer” and “Medicare for all” somewhat interchangeably, as does the Campaign for Guaranteed Healthcare.

To these groups, the focus on a “single government payer” is crucial.  They are very specific in saying that employers would no longer be responsible for health care costs and coverage decisions.  And they believe this structure is necessary both to reduce administrative costs and enhance negotiating power.  They don’t believe that other hybrid approaches, such as those Oberlander mentions, above, should be considered.

Messaging

To make it even more confusing, messaging strategy also plays into what terminology is used.

Because “single payer” may not be very meaningful to people outside of the rarified world of progressive health policy, “Medicare for all” seems to be gaining more traction.  By using the name of a familiar and popular program, Medicare, single payer supporters believe they can make the concept more approachable to more people.

Are they right?  This poll shows that Medicare for all is the preferred terminology.  In contrast, the June Kaiser Health Tracking poll finds little difference between the “Medicare for all” or “single payer” labels.

Whether one or more of the five terms listed under Goal in the first part of this blog would be any more popular is hard to say.  Herndon Alliance, a group formed in 2005 to work on messaging prior to the run up to the fight to pass what became known as the Affordable Care Act (ACA), conducted extensive market research on how to talk about health reform.  At the time, “quality, affordable health care” polled better than universal coverage.  Without current messaging research, it’s hard to know what is the “right” terminology to use now.

So, What DO We Mean by Single Payer?

For the purpose of this blog series, I am choosing to refer to single payer as a goal, rather than a specific policy prescription.

While we may not agree on terminology, or on policy solutions, at least most of us can agree on the goal: quality, affordable coverage and care for all, universal health care, guaranteed lifetime coverage for all or whatever you choose to call it.  And that is a good place to start the next phase of the discussion:  how to get there.

To read the rest of the blogs in this series, click here.

To Learn More

Here are a few resources about how other countries structure their health care systems:

Health Care Systems – The Four Basic Models: An excerpt from T.R. Reid’s book The Healing of America:  A global Quest for Better, Cheaper and Fairer Health Care, as featured in public television’s Frontline program, Sick Around the World.

Road to Single-Payer:  Understanding Different Universal Health Care Systems: Blog post by Jon Walker

Single Payer Is Not a Principle: Article in Democracy by Harold Pollack
(See especially the discussion under this heading: 2. Single payer provides one path to universal coverage.  There are many others.)

The fix for American health care can be found in Europe: Article in The Economist

International Profiles of Health Care Systems: Commonwealth Fund

In New Survey of 11 Countries, U.S. Adults Still Struggle with Access to Affordability of Health Care: Commonwealth Fund

 

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