As an elected member of the Family Voices National Board of Directors and Member of the Policy Committee my responsibilities include working closely with the Washington DC based Family Voices Policy Team on issues impacting families. When Congress is in session The Policy Team distributes “Washington DC Update” on a weekly basis. As you probably know the new administration and congress are making many legislative decisions that will impact families who have a family member with disabilities. It is my intent to post relevant information from the update on a regular basis. Below are excerpts from the Washington DC Update published on February 1, 2017. If you want to read the full newsletter or past issues please click here … Washington DC Update Past Issues.
Tom Rose, Executive Director – Family Voices Colorado
Greetings from Washington!
The new president has been in office less than two weeks and has been keeping up a fast pace of activity. After his January 20 Executive Order instructing federal agencies to limit activities related to implementation and enforcement of the Affordable Care Act (ACA), he halted ads and other outreach efforts to promote of the ACA open-enrollment period (which ended on January 31), but then changed his mind and re-instituted some of these efforts. He also issued an order to limit immigration from certain countries with Muslim majorities, causing consternation among medical schools with foreign students, and health care providers that employ foreign medical and nursing professionals and serve foreign patients in need of specialty care. Meanwhile, more Republicans in Congress seem to be expressing concern about a swift repeal of the ACA without having a replacement lined up, but there is no agreement on how to replace it. At his confirmation hearing, to be the new Secretary of Health and Human Services, Rep. Tom Price, MD (R-GA) made a surprising comment in support of the Children’s Health Insurance Program (CHIP). And new state-by-state resources are available about the impact of Medicaid and the ACA. Read about these issues and more in this week’s Update.
Supreme Court Nomination
On January 31, President Trump nominated Neil Gorsuch to the Supreme Court.
ACA Executive Order
As reported in last week’s Update, President Trump issued an Executive Order directing the Secretary of Health and Human Services and other applicable agency and department heads to use their discretion to limit implementation and enforcement of the Affordable Care Act (ACA or “Obamacare”) if it would cause a fiscal burden for any individual or entity, and to provide greater flexibility to states in implementing their health care programs. At this point, it is still unclear how great the impact of this directive will be. The National Health Law Program (NHeLP) has developed a Q & A information brief on this particular Executive Order (explaining its limits) and a one-page fact sheet on the nature of presidential Executive Orders in general.
ACA Enrollment Outreach
Just days before the end of the ACA open-enrollment period, the administration decided to halt advertising, “tweeting,” and other efforts to encourage consumers to purchase health insurance. Many advocates were concerned about this decision, some suggesting that it was an intentional move to undermine the law, because many younger, healthier people tend to enroll at the last minute and they are needed to ensure a balanced insurance pool. In a move that some experts thought could have a material impact, the administration stopped sending emails to encourage enrollment by individuals who visited HealthCare.gov but had not completed the enrollment process. The next day, however, the administration reversed its decision in part. It started to send out emails and tweets again, and said it would not pull ads that had been paid for already but would not purchase new ads.
As reported in earlier Updates, the House and Senate have adopted a concurrent budget resolution – the first step in the ACA repeal process. At this point it is entirely unclear when there will be any repeal and/or replacement legislation. A recording of a closed-door meeting at the Republican congressional retreat last week reveals disagreement within the party about how and when to proceed with repeal and replacement of the ACA. Some Members are anxious to get the repeal done, since that’s what the president and many Members of Congress promised during their campaigns. Others caution that they should proceed without haste, fearing that repeal without replacement will cause a collapse of the individual insurance market, which would be blamed on the Republicans. While most Members of Congress would probably be happy to replace the ACA at the same time they repeal it, there is no consensus on how to do so.
A particularly thorny issue involved in ACA repeal is what to do about the law’s Medicaid expansion. Before the ACA, childless adults were not eligible for Medicaid. The ACA as written would have required every state to provide Medicaid coverage to all individuals with incomes below 100 percent of the federal poverty level, providing significantly enhanced federal matching payments to states for the cost of covering those who were previously ineligible (the “expansion population”). The Supreme Court effectively made this Medicaid expansion optional for states. As of January 2017, 32 states (including the District of Columbia) have taken up the expansion option. Thus, if the Medicaid expansion provision of the ACA is repealed, these states will lose millions of federal dollars, with significant ramifications for the state’s health care providers, cities and counties, and/or taxpayers. This creates a dilemma for Members of Congress wishing to repeal the ACA and cut federal spending without hurting their own states that have expanded Medicaid. At least 8 Republican Governors are warning Congress about the consequences of repeal, including: Utah Gov Herbert, Massachusetts Gov. Baker, Arizona Gov. Ducey, Michigan Gov. Snyder, Ohio Gov. Kasich, Arkansas Gov. Hutchinson, Nevada Gov. Sandoval,and Kentucky Gov. Bevin. (See positions of specific Republican governors.)
A January 24 letter from the National Governors Association to congressional leaders reflects this problem. The letter requests that Congress consider several factors as they undertake health care reform, including the need to involve governors in the development of legislation. The governors seek flexibility, but say “it is critical that Congress continue to maintain a meaningful federal role in this partnership and does not shift costs to states,” and that reforms “should protect states from unforeseen financial risks – such as the recent economic downturn or higher costs due to new drugs, treatment, or epidemics – that could result in a spike in Medicaid enrollment or increased per-beneficiary costs.”
As noted in last week’s Update, Members of Congress have heard from many constituents who oppose ACA repeal in the absence of a simultaneous replacement. As of last week, at least 10 Republican Senators were on the record expressing concern about repeal without replacement, including: Sen. Alexander, Sen. Collins, Sen. Corker, Sen. Cotton, Sen. Flake, Sen. Isakson, Sen. Johnson, Sen. McCain, Sen. Murkowski, Sen. Paul, and Sen. Sullivan.
As noted above, there is no consensus about how to replace the ACA while retaining its popular consumer protections. Several Members of Congress have proposed ACA alternatives, but the administration has not yet done so. It is possible that it will, once Rep. Price is confirmed as HHS Secretary, assuming that happens. (There was an abrupt cancellation of a vote on his nomination scheduled in the Finance Committee on Tuesday.) Such a proposal could be based on a plan put forward by HHS Secretary-nominee Rep. Price in 2014 or a similar plan put forward by House Speaker Paul Ryan (R-WI) in his “Better Way” health care proposal. Among other things, both plans would provide tax credits to purchase insurance, encourage the creation of Health Savings Accounts (from which pre-tax dollars could be used to purchase health care), and allow the sale of health insurance plans across state lines. Senate Democratic Leader Chuck Schumer (D-NY) indicated that Senate Democrats would be willing to work with Republicans to develop an ACA replacement plan, but would do so only before repeal of the ACA.
Recently, several Senators have developed replacement bills:
Cassidy-Collins bill. On January 23, Senators Bill Cassidy, MD (R-LA), Susan Collins (R-ME), Shelley Moore Capito (R-WV) and Johnny Isakson (R-GA) released legislative text for the Patient Freedom Act of 2017, a comprehensive replacement plan for Obamacare. Among other things, the bill would repeal the ACA’s individual and mandates to have insurance, and its “essential health benefit” requirements while retaining some consumer protections, including the prohibitions on annual and lifetime limits, and coverage of treatment for mental health and substance use disorders. The bill would also create high-risk pools for people with pre-existing conditions. (For more details, see Senator Collins’ website.) During the past week, there have been several summaries and analyses of the Cassidy-Collins bill, including a thorough summary by Tim Jost, a blogger for Health Affairs, and an analysis from the Center for Budget and Policy Priorities. The National Health Law Program has prepared a three-page critique, Nine Things to Know About the Cassidy-Collins’ Replacement. Joan Alker, Executive Director of the Georgetown Center for Children and Families, blogged about the Cassidy-Collins proposal and the idea of ACA replacement in general.
On January 19, Senate Finance Committee Ranking Member Ron Wyden (D-OR), along with every Democratic member of the Committee, today sent a letter to all governors (Democrats and Republicans) asking for feedback on the expected impact of Republican proposals to block grant or cap Medicaid. Responses are requested by February 15. In December, Finance Chairman Hatch (R-UT) and the other Republican committee members sent a letter to all Republican governors and insurance commissioners asking for their input on Medicaid reforms and inviting the governors to a January Roundtable discussion about the issue. The Roundtable took place on January 19, with ten Republican governors participating.
On January 26, the Medicaid and CHIP Payment and Access Commission (MACPAC) held a meeting at which they discussed possible options for Medicaid restructuring, and released related reports. (See Information section, below.)
For some years, some conservatives have proposed restructuring the Medicaid program into a block grant to states – meaning each state would get a fixed amount based on its historical costs but not related to current state Medicaid enrollment numbers ̶ or paying states a limited amount per person covered (per capita cap). The Trump administration has also said it favors this type of Medicaid restructuring. Block grant proposals entail giving states much greater flexibility in determining Medicaid eligibility and benefits. Block grant proponents argue that this would allow states to innovate in ways that would serve beneficiaries more efficiently. But the congressional proposals to restructure the federal financing of Medicaid all involve cutting federal contributions to states compared to what they would get under the current entitlement structure of the program. Thus, states, localities and health care providers will have to bear relatively more and more costs as time goes on. See Republican ideas for healthcare reforms could spell trouble for U.S. states (Reuters article).
For more information about block grants and per capita caps, see:
The Senate is responsible for confirming Cabinet nominees, and its various committees are now holding confirmation hearings. If a relevant committee recommends confirmation, then the full Senate will vote on the nomination.
Secretary of HHS. Rep. Tom Price, MD (R-GA), a former orthopedic surgeon and long-time opponent of the Affordable Care Act, has been nominated to be the Secretary of Health and Human Services. Surprisingly, during his official confirmation hearing before the Senate Finance Committee on January 24, Rep. Price expressed his belief that funding for the Children’s Health Insurance Program (CHIP) should be extended – for eight years. As reported by The Hill, when asked by Ohio Sen. Sherrod Brown (D-OH) if he thought the funding should be extended for another five years (which was recommended by the Medicaid and CHIP Payment and Access Commission), Rep. Price replied: “Well, if we could extend it for eight, that’d probably be better than five.” (You can watch this exchange at the 1:55 point on the recording of the committee meeting.)
Secretary of Education. As reported last week, the Senate Health, Labor, Education and Pensions (HELP) Committee held a very long confirmation hearing for the nominee to be the Secretary of Education, Betsy DeVos, at which she seemed not to be very familiar with the Individuals with Disabilities Education Act (IDEA). (Watch the archived hearing; the IDEA discussion begins at the 3 hour and 31 minute mark.) Ms. DeVos subsequently wrote a letter to Sen. Isakson to clarify her views on that law. As explained in a Washington Post article, special education advocates were not reassured by her letter, however. After the hearing, some of the members of the Consortium of Citizens with Disabilities (CCD), including Family Voices, sent a letter to Chairman Alexander and Ranking Member Patty Murray (D-WA) to request that a vote on the nomination be postponed until Ms. DeVos answers additional questions (specified in the letter) regarding her views on policies affecting students with disabilities. The vote was not postponed in response, however. On January 31, the committee recommended, on a party-line vote, that Ms. DeVos be confirmed. Full Senate consideration of her nomination has not yet been scheduled. Given strong grassroots opposition to the nomination, reflected by calls to Senate offices, ultimate confirmation is not guaranteed.