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of the ACA are stripped out and/or bastardized immediately (and some, like the individual mandate penalty, are even repealed retroactively), but for the most part the pain doesn't start for another 2 years, well after the midterms are over.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:
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.
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.
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.
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.
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.
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.
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.
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:
It appears that a formal letter was sent to HHS Secretary Tom Price and CMS Administrator Seema Verma from the Energy & Commerce Committee of the House of Representatives...it's 6 pages long, and unfortunately the text isn't selectable, so I had to embed the pages as images. I'm happy to report that I contributed to their inquiry.
...and believe me, it wasn't on purpose; I've simply been swamped the past couple of weeks with other stuff, and somehow I just never got around to writing anything up about it.
I should have, though. Everyone thinks the existential threat to the ACA was over back on July 28th, and now it's simply a matter of "stabilizing the market" and "stopping Trump from sabotaging Open Enrollment". For the most part this is true, but for whatever reason, Louisiana GOP Senator Bill Cassidy and South Carolina GOP Senator Lindsey Graham simply won't let it go already, and are insisting on trying one final, desperate Hail Mary play to squeeze through an ACA repeal/Trumpcare bill as the final seconds run out on the 2017 Fiscal Year (which ends September 30th).
A week ago, Vox's Sarah Kliff reported that the Trump Administration was slashing the 2018 Open Enrollment Period advertising budget by 90% and the navigator/outreach grant budget by nearly 40%. As I noted at the time, the potential negative impact of these moves on enrollment numbers this fall--coming on top of the period being slashed in half, the CSR reimbursement and mandate enforcement sabotage efforts of the Trump/Price HHS Dept. and the general confusion and uncertainty being felt by the GOP spending the past 7 months desperately attempting to repeal the ACA altogether could be significant. In states utilizing the federal exchange (HealthCare.Gov), 2017 enrollment was running neck & neck with 2016 right up until the critical final week...which played out under the Trump Administration, which killed off the final ad/marketing blitz.
Result? A 5.3% total enrollment drop (or 4.7% if you don't include Louisiana, which expanded Medicaid halfway through the year) via HC.gov, while the 12 state-based exchanges--which run their own marketing/advertising budgets--saw a 1.8% increase in total enrollment year over year.