The Congressional Budget Office (CBO) and Joint Committee on
Taxation (JCT) on March 13 released a score, or assessment, of the American
Health Care Act, the House Republican Affordable Care Act (ACA) “repeal and
replacement” bill making its way through Congress.
CBO said several major provisions of the Republican proposal
would result in a decrease of $880 billion in direct federal Medicaid spending
and 14 million fewer enrollees from current levels to the year 2026. And next
year, in 2018 alone, 5 million fewer people would be covered by Medicaid, CBO
and JCT said.
The loss of the nearly $1 trillion in direct spending would
culminate “in 14 million fewer Medicaid enrollees by 2026, a reduction of about
17 percent relative to the number under current law. Some of that decline would
be among people who are currently eligible for Medicaid benefits, and some
would be among people who CBO projects would be made eligible as a result of
state actions in the future under current law (that is, from additional states
adopting the optional expansion of eligibility authorized by the ACA),” CBO and
JCT said.
Congressional Republicans and the Trump administration want
to end the open-ended funding system Medicaid has always operated under and
replace it with a per-capita cap on federal spending, allocating to the states
funds that they can disperse to enrollees as they see fit.
CBO and JCT said “some decline in spending and enrollment
would begin immediately, but most of the changes would begin in 2020, when the
legislation would terminate the enhanced federal matching rate for new
enrollees under the ACA’s expansion of Medicaid and would place a per
capita-based cap on the federal government’s payments to states.”
The long-awaited CBO/JCT numbers stand in contrast to
the administration’s statements on how the Republican bill would impact coverage
for not only Medicaid, but also for non-group market enrollees. Last week on
March 10, Health and Human Services (HHS) Secretary Tom Price said on MSNBC
that the ACA replacement
bill would not result in anyone losing coverage. “We don’t believe that
individuals will lose coverage at all, so long as they’re able to select the
kind of plan that they want for themselves and for their family,” Price told
the network.
Even
before CBO and JCT released their report, health care experts said the long
term care community’s worry about the Medicaid program and the loss of federal
funds under a per-capita cap were warranted. “The highest level of analysis says
this is going to significantly reduce the federal contribution to Medicaid,” Howard
Gleckman, senior fellow, Urban Institute, tells Provider.
“Medicaid either provides benefits to fewer people or states
decide to reduce benefits,” he adds. “There is no way around it. A per-capita
cap mostly means less money to provider services for each beneficiary.”
Gleckman also says there will likely be a “Shark Tank”
effect on states and Medicaid funding, with representatives from the various
“buckets” of people who currently are served by the program fighting one
another for funds from the per-capita caps. “Per-capita caps are probably better
than the pure block grant alternative, where there would be one pot of money
available for everybody,” but even under the Republican cap idea the “resources
for LTC will still decline.”
And
criticism also came from within HHS on the Medicaid plans of the Republican
legislation. Andrey Ostrovsky, MD, chief medical
officer of the Center for Medicaid and CHIP Services, on March 8 tweeted a
blunt rejection of the proposal. His message said, “despite political messaging
from others” at HHS, he sided with provider and physician groups in opposing
the Republican bill’s impact on the Medicaid program.
The next steps for the Republican health care proposal is for
the House Budget Committee to combine the different parts of the bill on March
15. The House Energy and Commerce and Ways and Means committees approved two
different parts of the repeal and replace legislation on March 9, and now it
has to be unified before being sent to the House Rules Committee and possibly the
House floor for a vote during the week of March 20. The Senate, under House
Speaker Paul Ryan’s (R-Wis.) schedule, would take up the bill the week of March
27.
But, some Senate Republicans continue to speak out
against not only the Ryan timetable but also the content of the legislation,
with one of the most vocal being Sen. Tom Cotton (Ark.). On March 13, Cotton
said on a conservative talk show that the discussion by Ryan and the Trump
administration of a three-phased approach to repealing and replacing the ACA is
just “politicians’ talk,” and is not achievable in the Senate.
Price last week said the American Health Care Act was
just the first of three phases, with the second being regulatory changes by the
administration and the third being additional legislation, like to allow the
sale of health insurance across states lines. But, Cotton pointed out to the
radio show that while the repeal and reform bill only needs 50 votes to pass
the Senate under “reconciliation” rules, the additional legislation would need
60, which may not happen with Republicans only holding a 52-48 majority.
In a possible White House
move to shore up support for “repeal and replace” in the Senate, Sen. James Lankford (R-Okla.) on
March 13 told The Hill newspaper that
he and other conservatives in the Senate Republican Steering Committee have
talks scheduled at the White House. Conservatives in both the House and Senate
object to the current language in the repeal and replace bill, calling it
“Obamacare Lite,” in reference to refundable tax credits and other measures
that either mimic or maintain ACA provisions. Meanwhile, Democrats have not
wavered from their dislike of any Republican effort to gut the ACA.
The
machinations of the conservative bloc in Congress has mystified some analysts,
who don’t understand its strategy. “There seems to be a fundamental
misunderstanding among Republican conservatives—both members of Congress and
outside groups—on how Republicans can ‘repeal’ and ‘replace’ the ACA,” said
Chris Condeluci, principal of CC Law and Policy, and former Republican Senate
Finance Committee staffer who worked on ACA negotiations in 2009 and 2010.
“In short, a
‘reconciliation’ bill can only impact 1.) spending and 2.) taxes. Which
means, you cannot ‘repeal’ and ‘replace’ all of the ACA’s insurance market
reforms through the ‘reconciliation’ process,” he said. “But,
for some reason, Republican conservatives don’t want to accept the reality of
the conditions that come with passing legislation through the ‘reconciliation’
process.”
Instead, Condeluci says, they want to engage in a
public display of civil disobedience in hopes that Senate leadership takes
extreme measures, like eliminating the 60-vote threshold rule, or firing the parliamentarian,
or encouraging Vice President Pence to overrule the parliamentarian to allow
full repeal of all of the insurance market reforms on the Senate floor.