GRAHAM-CASSIDY REPEAL BILL DEADLINE:

Time: D H M S

BREAKING: House GOP orders Senate GOP to get AARP to quit yelling at them

This morning Yesterday I noted that Paul Ryan, who apparently just remembered that yes, older white people tend to a) vote in midterms and b) vote Republican, has decided to take measures to win over the missing votes he needs to drag his dumpster-fire-of-a-healthcare bill over the finish line.

The changes in question appeared to include a) hurting even more poor/disabled people more quickly than before by speeding up the Medicaid expansion cut-off and block-granting non-ACA Medicaid...but also a vague reference to beefing up the individual market tax credits for older enrollees.

Now the Medicaid cruelty aside, I've long been an advocate of beefing up the indy market subsidies myself, so this isn't necessarily a terrible idea, although the devil would be in the details. I assumed, for instance, that Ryan & Co. planned on changing the age-based structure from this:

...from this... ...to something like this...
  • <30 years: $2,000
  • 30-39: $2,500
  • 40-49: $3,000
  • 50-59: $3,500
  • 60-64: $4,000
  • <30 years: $2,000
  • 30-39 years: $4,000
  • 40-49 years: $6,000
  • 50-59 years: $8,000
  • 60-64 years: $10,000

    ...since this would make for a 5:1 credit ratio to match the 5:1 premium age band under the Trumpcare bill. This would still be kind of a stupid way of doing it, and it would wipe out the $336 billion in "savings" which is the only positive thing the GOP can point to in the CBO's score...but at least it would be easy to understand and extremely simple to change on short notice (literally, just an amendment to swap out the original dollar amounts for the new ones).

    Instead, however they're apparently going a different route:

    In an effort to blunt the disastrous impact of the American Health Care Act on older Americans, House Republican leaders are adding a provision that would set aside $75 billion to do ... something unspecified.

    Really. According to Politico, the new version of the bill will not say at all what to do with the $75 billion. Instead it will just “instruct the Senate” to come up with a plan to use the money to help people between the ages of 50 and 64.

    This is a very unusual way to legislate and reflects House Republicans’ desperation to pass basically anything as soon as possible and pass the buck to the Senate.

    In other words, Ryan and the House GOP are getting tired of old people screaming at them at their town halls, so they're demanding that the Senate cough up $75 billion to get the AARP to quit pestering them.

    In one sense, this is an example of what democracy is supposed to look like: Representatives responding to the will of their constituents. On the other hand, there appears to be absolutely no thought or logic to this decision beyond "THROW GOBS OF MONEY AT THE PROBLEM TO MAKE IT GO AWAY!!"

    ...which, of course, is exactly what Republicans/conservatives are constantly mocking Democrats/liberals for supposedly doing.

    Now, my own sloppy back-of-the-envelope math from earlier today suggested that they'd have to pony up more than three times that much in the form of increased credits in order to resolve the high-premium issues, but perhaps I'm way off base. Perhaps $75 billion is enough to cut those older-enrollee premiums down to size...at least, enough to calm the AARP down

    But I seriously doubt it. This gambit doesn't strike me as being a well thought-out, carefully-considered improvement; it seems very much like, as Matt Yglesias put it, a desperate move to cram something through the House purely so they can say "There! See! We said we'd repeal Obamacare and by gum, we did it!"

    UPDATE: OK, Ezra Klein (also of Vox.com) has confirmed the other key details of the revisions:

    • A fund of $75 billion that the Senate could use to boost tax credits for older Americans;
    • More flexibility for states to add work requirements to Medicaid;
    • More flexibility for states to take their Medicaid funding as a lump-sum block grant rather than a per-person check;
    • Accelerating the repeal of Obamacare’s tax increases by one year;
    • Restricting people from rolling unused tax credit money into health savings accounts (apparently to ease concerns of anti-abortion groups);
    • Changing Medicaid reimbursement procedures in a way that advantages county governments over state governments (for idiosyncratic reasons, Republicans from New York are high on this provision);
    • Changing Medicaid reimbursement rates for the elderly and disabled.
    • States that haven’t accepted Obamacare’s Medicaid expansion will no longer have the opportunity to do so.

    The $75 billion I discuss above; I also made note of a couple of the Medicaid provsions (note that 5 of the 8 changes are Medicaid-specific, and 3 of those objectively damage the Medicaid program and enrollees; I'm not sure about the "county government" or reimbursement rate changes).

    "Accelerating the repeal of Obamacare's tax increases by one year" basically means that the $336 billion in savings, which has already presumably been knocked down to $261 billion, will be lower still. I'm not sure how much the ACA taxes are set to generate this year--perhaps $50 billion or so?

    The final change appears to be the prohibition on "rolling unused tax credit money into HSAs", which seems, again, somewhat illogical to me from a GOP perspective: I thought they loved Health Savings Accounts! It was my understanding that Republicans dreamed about HSAs as much as Paul Ryan used to dream of ripping away poor people's healthcare altogether back in his kegger days. But alas, apparently "oh noez! they might use the money for abortions!" was a bridge too far, so out it goes. FREEDOM!!

    UPDATE: OK, here's the actual amendment summary:

    • The original Trumpcare bill got rid of practically all of the taxes used by the ACA to pay for the tax credits and Medicaid expansion, but would keep them around for one year. The only tax it would've kept was, ironically, the "Cadillac" tax on high-end employer plans...except that it would've delayed implementation of the Caddy tax until 2025, making it mostly meaningless. Well, the revised version would make it completely meaningless by bumping it out another year, to 2026!
    • Currently, some states have the option of expanding Medicaid even further (ie, beyond the 138% FPL threshold) by special arrangement. Since the GOP is trying to kill off the current expansion, obviously they're not gonna let anyone go beyond where it's at now: No more >138% FPL expansion no matter what (officially it's 133%, but due to some weird legalese it's effectively 138%).

    I think this is the part where the House basically just punts to the Senate and orders them to figure out a way to get the AARP to quit chewing them out:

    Page 19. This section of the amendment accelerates relief from the Medical Expense Deduction by one year (effective beginning in 2017) and makes necessary conforming changes. It also reduces the qualifying adjusted gross income threshold from 10 percent to 5.8 percent— which is lower than the pre-Obamacare level of 7.5 percent. The latter policy will provide additional support for Americans with high health costs— including low- and middle-income seniors.

    • States are allowed to impose work requirements for adults who are not...

    Pregnant; Children under the age of 19; the only parent or caretaker of a child under the age of 6; the only paent [sic] or caretaker of a child with a disability; or under the age of 20 who is married or is the head of the household and maintains satisfactory attendance at school or participates in education directly related to employment.

    Typo aside, this means that if you're a low-income single parent who takes care of a 7 year old, you better have a job or you're SOL. Granted, 7-year olds should be in school...but that's only half the year. What if you don't have any relatives/friends/etc who can help take care of the kid for awhile? Too bad.

    Oh, and because Republicans are absolutely obsessed with requiring people to work in order to receive healthcare, and because they apparently do realize that monitoring/administering compliance with such a requirement would be an expensive, cumbersome pain in the ass...

    To ensure that states have the tools capable to implement the work requirement, the amendment provides a 5% administrative FMAP bump to states who choose to implement a work requirement.

    I'm not sure whether that means that Michigan, for instance, would go from the federal government paying 64.78% of Medicaid costs (as is currently the case) to 69.78%, or from 65% to 68.02%. Either way, that sounds like it'd add up pretty quickly. The average non-expansion Medicaid enrollee costs around $5,790 per year total. 5% of that is around $290 per person. Assuming all 50 states were to take them up on this, that'd be around 56 million people nationally, or $16.2 billion per year. Even if it's calculated as a percentage of the existing FMAP level, that'd still be a minimum of 2.5%, or $8.1 billion nationally.

    Obviously, not all 50 states would participate...I'm guessing that states representing perhaps half the Medicaid population might do so, which likely means a good $8 billion per year, or close to $100 billion over 10 years (with inflation).

    UPDATE: OK, I totally misunderstood this: David Anderson of Balloon Juice informes me that the 5% FMAP increase would only apply to administrative support, not to actual Medicaid claims...which means that we're not talking about billions of dollars after all, but much smaller amouts purely to cover the additional paperwork/red tape headaches. Which is "good" in the sense of not hitting the federal budget more, but bad in the sense that it wouldn't help the states much.

    Assuming that Medicaid administrative costs are, say, 5% of the total program, that'd be roughly $15 billion per year...so 5% of that would be around $750 million, again assuming all 50 states participated. I don't know what it would actually mean in administrative dollars, but it sounds like a fairly minor item after all.

    Update: Emma Sandoe, who knows Medicaid inside and out, confirms that 5% admin costs is about right.

    It also looks like the revision would actually increase provider reimbursement rates for Medicaid in a few situations, which is probably a good thing. Ironically, I actually have no problem with the feds increasing their portion of Medicaid funding--after all, part of the Single Payer philosophy is shifting more healthcare expenses to the federal government.

    HOWEVER, between the $75 billion "Mystery Fund", the 5% FMAP work requirement bribe, getting rid of the various taxes a year earlier and delaying the only remaining tax until a year later, it seems to me that these changes would end up wiping out pretty much all of the $336 billion in savings which the CBO cited as pretty much the only positive part of the bill in the first place.

    UPDATE: OK, I’m hearing more and more that it’s estimated to be more like $85 billion instead of $75B...and apparently the “extra” funding would come from reducing the amount of medical expenses which could be deducted from your taxes from 10% down to 5.8%.

    Honestly, the only positive effect I see here comes from the $75B Mystery Fund, and even that's not certain...nor is there any guarantee that it would actually be used to cut down premiums for older enrollees anyway. As far as I can tell, it might chop down the number of people being kicked off of their coverage by a bit, bringing it down to perhaps 22 million or so instead of 24 million. Yay, team.

    Of course, the only reason the CBO projected premium rate growth to come in 10% lower than under the ACA by 2026 in the first place is because several million older people were expected to be kicked to the curb...so if they don't drop out, guess what happens to those 2026 premiums after all?

    Gee...who would have guessed that healthcare is hard!

    P.S. Oh, and there's this amusing tidbit from Paul Ryan's official statement on the revisions:

    Under jurisdiction of the Ways and Means Committee: Moves up repeal of Obamacare taxes from 2018 to 2017, strikes a provision allowing excess tax credits to be deposited into Health Savings Accounts, and provides budgetary space for the Senate to increase tax credits for older Americans. 

    I love that. "Provides budgetary space for the Senate"...aka "HOT POTATO!! It's your problem now, Mitch! DO SOMETHING!!"