Graham-Cassidy Failed. Now What?

By Jill Zorn

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This week marked another failure of Congress to pass a bill to repeal and replace the Affordable Care Act (ACA).   This time it was the Graham-Cassidy bill that couldn’t find the votes to be passed in the Senate and then sent to the House.

As Politico reports,

At one point, the bill seemed to have a real chance of success. And then it ran into the same hurdles that killed every other GOP health plan. Ultimately, a number of Senate Republicans remain wary of transforming the U.S. health system in such a haphazard process — especially with plans to make deep cuts to Medicaid and roll back protections for people with pre-existing conditions.

Why did the bill fail?

A terrible process

The beginning of the end of Graham-Cassidy began on Friday, September 22, when Senator John McCain announced that he could not “in good conscience” vote for the bill.  Just as he had on a previous repeal effort he objected to the rushed and unusual process that broke well-established norms in the Senate for law-making.  Read his statement here.

Another Senator, quoted in Politico, expressed similar concerns about the messy process:

“I can’t be on CNN defending something if it’s in its 27th iteration when I think it’s the third iteration. That’s not the way I do business,” said Sen. John Kennedy (R-La.). “I don’t even know what the last version looked like.”

Too much division within the Republican party

There seems to be no way to satisfy both the extreme right and the more moderate wings of the party.  As Sarah Kliff wrote in Vox:

There is no clear ground between the Senate moderates and conservativesAny future Republican repeal efforts will confront the same obstacle as those we’ve seen fail in recent months. There appears to be no policy middle ground between someone like Sen. Rand Paul (who wanted to see the insurance markets completely deregulated) and Sen. Susan Collins (who wanted to ensure nobody in her state lost coverage).

Supporters of repeal and replace don’t agree on their goals

It turns out that “repeal and replace” is a slogan, not a plan.  Reporter Dylan Scott interviewed policy experts in conservative think tanks for his Vox article, Obamacare Repeal Died Again.  Republicans Have No Plan B:

“There really wasn’t a robust and serious conversation about what is the conservative or Republican solution to health care policy,” Dan Holler, who oversaw the repeal debate for Heritage Action for America, told me. “There was really no consensus within the Republican Party on where to go forward.”

The public is against repeal

The one hearing held on the Cassidy-Graham bill was targeted by a large group of protesters, many of them from the disabled advocacy group ADAPT.  These demonstrators illustrated the reality that Americans were against this bill.  A poll taken just a few days before the hearing showed only 20 percent of those asked approved of the legislation.

The visible opposition of talk show host Jimmy Kimmel may have also helped stop the bill.  Another poll shows voters trusting him more on health care issues than they trust Republicans in Congress.  His message about needing to make sure people with pre-existing conditions retained coverage was one that resonated with the public.

Ironically, the result of the past tumultuous months of repeal attempts is that the ACA is now more popular than ever.

Maybe ACA repeal failed for this simple reason, articulated by Ezra Klein in his Vox article Why Obamacare Survived:

The secret to Obamacare’s persistence is that the American people want the health care system made better — by which they mean they want more people to have affordable health insurance — and Obamacare achieves that goal. By contrast, the GOP, at every single turn, has offered plans to make the system worse.

What’s Next?

The next federal fiscal year begins on Monday.  Does that mean we have to be ready immediately for another attempt at repeal?

The good news is, it seems we will get a brief reprieve, while congress turns its attentions to a tax reform package.  But the bad news is possible repeal of the ACA is not likely to go away completely until there is political change in Washington D.C.

The danger of repeal using the reconciliation process is certainly far from over and this article games out some of the possible routes.  In fact, Senators Graham and Cassidy emerged from a meeting with the president yesterday vowing to hold hearings and keep trying to pass their bill.

At the same time, repealing the ACA next year will not be easy and faces clear obstacles.  And talk of a bipartisan compromise to stabilize the marketplaces is again in the air.

It’s impossible to predict the future in this extremely volatile political environment.  But there is no question that advocates will have to remain vigilant.

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Maria Wreaks Havoc on Puerto Rico – American Lives Are at Stake

By Stephanye R. Clarke

PR

Maria, a category 5 hurricane with destruction on her mind, set her sights on Puerto Rico last week and plowed through with reckless abandon, crippling the already-struggling island; annihilating the power grid and communications; and obliterating communities.

In our last storm-related blog, Harvey had devastated Houston and other Texas communities; Irma mercilessly pummeled Florida and the US Virgin Islands.

Last week, reports of widespread power outages flooded Facebook and Twitter timelines—at one point there were reports that the entire island was without power. This article describes many ways the lack of power exacerbates the existing crisis in Puerto Rico.

A FEMA press release indicates that forces are on the ground to aid in distribution of food, water and other critical supplies. However, several reports also indicate that efforts are not-well coordinated. The airport in San Juan is barely operational, thanks to limited power via generators, leaving many stranded in sweltering conditions with no food or water. The threat of the collapse of the Guajataca Dam has compounded already tense and frustrating circumstances.

The road to rebuilding, perhaps particularly on the islands, will be long and requiring major resources and supports. Many on the mainland anxiously await updates from their loved ones on the island. There are reports that millions of residents may have to wait months before power is restored. This means that schools, businesses, health care facilities, banks, etc. are unable to provide essential services to those in need.

Devastation is so widespread that it’s impossible to know how soon Puerto Rico will be able to recover. Gov. Ricardo Rossello requested that as much attention be paid to Puerto Rico as was paid to Texas and Florida.

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“Tears for Puerto Rico” by Rosie Rosado (Artist/Model)

And what of the health of our fellow Americans? With hospitals and health care centers completely or nearly out of commission, the need for medical supplies and medications is critical, as is the list of immediate needs for people to get through the next several weeks and months. And long after the power grid, cellular towers, schools, businesses, banks, churches, and hospitals are fully online, the trauma of loss, fear and hopelessness will likely still haunt residents.

To donate online to relief efforts visit Hispanic Federation at www.hispanicfederation.org or click here for a list of agencies. To stay up to date on other efforts happening around the state, be sure to “like” the Connecticut Puerto Rican Agenda’s Facebook page.

I’ll end this blog like we ended the last one:

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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The Time is Ripe for a Health Care Action Summit

By Lynne Ide

Protect+Our+Care+CTWhat a year 2017 has been so far for health care advocates and activists!

We have faced down multiple Washington-based attempts by the GOP to decimate gains in health care coverage and protections made in the past eight years. (We are in the midst of work to stop the dangerous Graham-Cassidy bill now!)

We have given voice to people’s concerns about what still needs to done to take on rising health care premiums and prescription drug costs.

We have rallied to protect Medicaid for the families that need it and access to women’s health services.

At the center of all this work in our state is a growing network of organizations and individuals coordinating health care advocacy efforts through the Protect Our Care CT Campaign.

Protect Our Care CT is hosting a statewide Health Care Action Summit on Saturday, October 14, 8:45 am – 3:30 pm in Meriden.

The one-day Summit will bring together people from across the state – grassroots leaders from new organizations, long-time health care advocates and anyone else who cares about working for quality, affordable health care we can all count on.

The agenda will feature a variety of health policy and organizing/advocacy skill building workshops. There will also be dynamic speakers, and a chance to mingle with political leaders and candidates in the afternoon. The event will address federal and state-based advocacy and organizing opportunities and challenges.

The Summit is designed to lay the groundwork for our work together in 2018 and beyond.

Won’t you consider joining us on October 14? Find out more and register here.

Check out Protect Our Care CT Campaign’s summer “Lives on the Line” action videos:

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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.

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  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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