GRAHAM-CASSIDY REPEAL BILL DEADLINE:

Time: D H M S

OK, Indivisible is all over the Graham-Cassidy disaster, so rather than try and cobble together my own action list, I'm cribbing from their email missive. I'll also be posting the latest Graham-Cassidy developments throughout the day.

STOP THE RETURN OF TRUMPCARE. TrumpCare is back and Republicans are as close as they’ve ever been to passing it. There are 12 days left for the Senate to ram healthcare through reconciliation with just 50 votes. This is TrumpCare’s last stand. Call your senators ASAP and tell them to vote no on “Graham-Cassidy” using all the latest resources at TrumpCareTen.org.

TrumpCare is back. REPEAT: TrumpCare is back. We really hoped we’d never have to say that, but you should know by now that this is the bill that just won’t die. Because of the rules of reconciliation, the special process Republicans are using to jam TrumpCare through the Senate, they have until September 30 to finish the job of repealing the Affordable Care Act. That gives them 12 more days to make good on their seven-year promise to repeal the Affordable Care Act. And nothing motivates Congress like a deadline.

The fact that the Graham-Cassidy bill, like all of the prior Republican "replacement" healthcare bills, screws over people on both Medicaid and the individual market starting in 2020 is hardly news. A few provisions of the ACA are stripped out and/or bastardized immediately (and some, like the individual mandate penalty, are even repealed retroactively), but for the most part the pain doesn't start for another 2 years, well after the midterms are over.

However, JP Massar called something to my attention this morning:

Graham-Cassidy, Sections 102 and 103:

Section 102: Modification and Repeal of Premium Tax Credits

  • Excludes from the definition of QHP a plan that provides coverage for abortions (except if necessary to save the life of the mother or if the pregnancy is the result of rape or incest), beginning tax year 2018.
  • Repeals the ACA premium tax credits as of January 1, 2020

Section 103: Modification and Repeal of Small Business Tax Credits

 

Regular readers know that one of the issues I've spent the better part of the past year yammering on about endlessly is the importance of Congress formally appropriating Cost Sharing Reduction reimbursement payments to the insurance carriers on the individual market exchanges.

Thanks to the ongoing/pending ruling in the federal House vs. Burwell Price lawsuit, Donald Trump has the ability to pull the plug on CSR payments pretty much whenever he wants to (and he's threatened to cut them off every month since around March or April so far). CSR payments hang like a Sword of Damocles over the heads of every exchange-based insurance carrier each month, with them never knowing whether they'll get reimbursed or not.

Just posted on the Congressional Budget Office's official blog:

CBO aims to provide preliminary assessment of Graham-Cassidy bill by early next week

CBO is aiming to provide a preliminary assessment of the Graham-Cassidy bill by early next week. That assessment, which is being prepared with the staff of the Joint Committee on Taxation, will include whether the legislation would reduce on-budget deficits by at least as much as was estimated for H.R. 1628, the American Health Care Act, as passed by the House on May 4, 2017; whether Titles I and II in the legislation would each save at least $1 billion; and whether the bill would increase on-budget deficits in the long term. CBO will provide as much qualitative information as possible about the effects of the legislation, however CBO will not be able to provide point estimates of the effects on the deficit, health insurance coverage, or premiums for at least several weeks.

Lovely.

August 11, 2017:

Anthem said Friday afternoon it planned to scale back statewide individual coverage in Virginia on the public exchange under the Affordable Care Act amid inaction by the Donald Trump White House on cost-sharing reduction subsidies.

Anthem, which operates under the Blue Cross and Blue Shield plan in 14 states, has already scaled back its Obamacare offerings in Indiana, Ohio and Wisconsin amid an unstable individual market for plans operating under the ACA.

“Today, planning and pricing for ACA-compliant health plans has become increasingly difficult due to a shrinking and deteriorating Individual market, as well as continual changes and uncertainty in federal operations, rules and guidance, including cost sharing reduction subsidies and the restoration of taxes on fully insured coverage,” Anthem said in a statement Friday afternoon. “As a result, the continued uncertainty makes it difficult for us to offer Individual health plans statewide in Virginia.”

Just a few days ago I noted that Michigan's Dept. of Insurance issued the semi-final 2018 individual market rate changes for the 10 carriers offering indy policies in the state (9 of which are on the ACA exchange; one of them is only offering plans off-exchange). At the time, the breakout was roughly 16.8% average increases assuming CSR payments are made next year or 26.8% assuming they aren't made.

Just moments ago, however, the Detroit News reported that Health Alliance Plan (HAP) is out at the last minute:

A major health insurer is leaving Michigan’s individual marketplace, ending its policies offered here under the Affordable Care Act as the federal government slashes funding for enrollment and outreach groups.

Hey Michigan Residents! Do you live in the SAGINAW area?

If so, come on out to Saginaw on Saturday, September 16th, and join former State Senator (and current gubernatorial candidate) Gretchen Whitmer, State Representatives Vanessa Guerra Adam Zemke, Chief Public Health Advisor for Flint Dr. Pam Pugh and myself as we explain what the latest craziness is regarding the ACA, the GOP attempts to repeal and/or sabotage it and healthcare policy in general from 10:00am - 12:00pm at IBEW Local 557 at 7303 Gratiot Road.

For the next two weeks, ALL HEALTHCARE-RELATED ATTENTION needs to be on the following three issues:

FIRST: September 27th is the final deadline for ACA exchange insurance carriers to actually sign the contracts to participate in the 2018 Open Enrollment Period. Yes, the deadline to submit their rate filings already passed a week or so ago, and most of them are fairly settled in for next year, but until they actually sign the contract, they can still bail from the individual and/or small business exchanges...and given the massive uncertainty over Cost Sharing Reduction reimbursements and other sabotage efforts of Trump and Tom Price as well as the ongoing repeal/replace saga by the Congressional GOP, many (most?) of the carriers are deliberately waiting until the last possible minute to do so.

Well this was unexpected, although I suppose I should have expected it given all the insanity surrounding the impending deadlines for insurance carriers to sign contracts (Sept. 27th, I believe); the end of the fiscal year on Sept. 30th (which is also the last chance for the GOP to try and squeeze through the hideous Cassidy-Graham Hail Mary repeal/replace bill); and the start of Open Enrollment on November 1st.

The CBO has issued a 17-page report with their latest projections for the types of healthcare coverage and federal spending on healthcare programs including Medicaid, CHIP, ACA tax credits and so forth over the next decade. here's what they foresee:

The federal government subsidizes health insurance for most Americans through a variety of programs and tax provisions. In 2017, net subsidies for people under age 65 will total $705 billion, CBO and the staff of the Joint Committee on Taxation (JCT) estimate.

Louisiana was one of the last states I ran rate hike analysis on just a month ago: Three carriers on the exchange (plus the "Freedom Life" phantom carrier), averaging around 21.4% rate increases on the assumption that CSR payments won't be made. According to the Kaiser Family Foundation, loading CSRs onto Silver plans only would bump them up by an additional 20 points; this translates into roughly 14.2 points if spread across all metal levels on & off the exchange. Based on that, I estimated LA's rate increases at 21.4% without CSRs but only 7.2% if they actually are paid.

Thanks once again to Louise Norris for doing the grunt work regarding the approved rate changes, which are...pretty much identical to what was requested by the carriers:

Proposed 2018 rates much higher than they would have been if CSR funding had been appropriated early in 2017

I ran an updated analysis of the requested average rate hikes for Connecticut last month. At the time, the only two carriers operating on the CT exchange next year (Anthem and ConnectiCare) were still noncommittal about actually committing to doing so. Statewide, it looked like the carriers were asking for rate increases averaging around 23.8% if CSR payments were guaranteed or 33.5% if they weren't.

As reported by Louise Norris today, the Connecticut insurance dept. reported that both carriers have now committed to sticking around next year, and the approved average rate increases now assume that CSR payments won't be made after all. In the end, the statewide average looks like roughly 28.4% (Norris pegs it at 29.3%, but that's because she generally only includes individual market carriers participating on the ACA exchanges, while I also include carriers and plans offered off-exchange as well).

I've written not one, not two, but three different blog entries in the past 24 hours about Bernie Sanders' just-announced "Medicare for All" proposal...but the reality is, I shouldn't have. Frankly, while it's a discussion/debate that we do need to have, making a big thing about it right this moment is, the more I think about it, terrible timing, because the Affordable Care Act is still in being attacked and at risk in several ways:

  • FIRST: The CSR issue still hasn't been resolved, although at this point it's extremely unlikely that Patty Murray and Lamar Alexander are going to pull a CSR/reinsurance rabbit out of their hats after all. Last week things looked somewhat promising, but this week it appears to have gone off the rails again...and with just 17 days left in the fiscal year (and, I believe, only 14 days before the contracts have to be signed by carriers for 2018 exchange participation), there's almost no time left to get even a minor stabilization bill pushed through.
  • SECOND: On a related note, Bill "so much for the Jimmy Kimmel test!" Cassidy and Lindsey Graham are still trying to cram through their pile-of-garbage Hal Mary Trumpcare bill, which is at least as bad as the GOP's failed AHCA/BCRAP bills were earlier this year and even worse in some ways. Again, there's only 17 days left to pull it off, but remember what happened with AHCA last spring...anything's possible. Here's a summary of the impact of the Cassidy-Graham bill via Andy Slavitt and the Centers for Budget & Policy:

OK, here it is. I've linked to a PDF with the full legislative text at the bottom of this blog entry; here's the summary version, with some notes:

TITLE I—ESTABLISHMENT OF THE UNIVERSAL MEDICARE PROGRAM

Establishes a Universal Medicare Program for every resident of the United States, including the District of Columbia and the territories. Guarantees patients the freedom to choose their health care provider. Provides for the issuance of Universal Medicare cards that all residents may use to get the health care they need upon enrollment. Prohibits discrimination against anyone seeking benefits under this act.

OK, so it apparently would cover undocumented immigrants, and every doctor/hospital/clinic/etc. would be required to participate, with anyone in the country being covered by any healthcare provider nationally.

The official announcement is scheduled for Wednesday, presumably with much hoopla accompanying it (and a dozen or so Democratic Senators co-sponsoring it, many of whom are considered likely 2020 POTUS candidate prospects). Over at the Washington Post, Dave Weigel has a sneak peak. I'll wait until I've had a chance to read through the actual text of the bill itself to write up a full response/analysis, so I'll just post a few key excerpts from Weigel's piece for now:

Sanders’s bill, the Medicare for All Act of 2017, has no chance of passage in a Republican-run Congress. But after months of behind-the-scenes meetings and a public pressure campaign, the bill is already backed by most of the senators seen as likely 2020 Democratic candidates — if not by most senators facing tough reelection battles in 2018.

For the past year and a half, of all the proxy battles between "Team Hillary" and "Team Bernie" on the left side of the aisle, no issue has been more repsentative of both how passionate people are or how much each "side" misunderstands the other than the future of the American healthcare system.

"Team Bernie", in essence, consisted of progressives (and Democrats) who believe that while the ACA may have improved things to some degree in some ways, it not only isn't enough long-term, it isn't nearly enough short-term either; the next step (and for many, the only acceptable next step) must be moving the entire U.S. population over to a universal Medicare-style Single Payer system, with everyone in the country being covered through a single, comprehensive healthcare program funded entirely (or nearly entirely) by taxes.

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