jeudi 27 juillet 2017

GOP Finally Releases ‘Skinny’ Repeal Bill: The Health Care Freedom Act

After several days of mystery and voting for and against amendments on a bill that doesn’t really exist, Republican leadership in the Senate has finally released the text of the Health Care Freedom Act, better known as the “skinny” Obamacare repeal bill.

The Senate Budget Committee released the bill [PDF] via Twitter shortly after 10 p.m. ET on Thursday night. We presume they were waiting to see who was evicted from Big Brother.

The 8-page bill does the following:

• Negates the “individual mandate” — the requirement that all people must have some form of insurance or pay a penalty — by reducing the penalty for not having insurance to $0. This appears to be effective immediately and retroactive to the beginning of 2016.

• Negates the “employer mandate” — the requirement that businesses of a certain size must provide full-time employees with qualifying coverage — by reducing the penalty for not having insurance to $0. This appears to be effective immediately and retroactive to the beginning of 2016, but returning in 2025.

• Delays the tax on medical device manufacturers through 2020.

• Allows for increased maximums on Health Savings Accounts, starting in 2018.

• Denies federal funds to Planned Parenthood (or any similar program, but the definition is so specific that it’s really just Planned Parenthood) for one year.

• Shuts down all funding to the Prevention and Public Health Fund, which provides funding to a variety of public health concerns, like Alzheimer’s research, diabetes prevention, heart disease prevention, anti-smoking initiatives, immunization, scientific support for state and local officials to detect and respond to outbreaks, and much more. This fund is about 15% of the entire budget for the Centers for Disease Control and Prevention. Funding would end starting in 2018, with no replacement offered.

• Allows states to seek “innovation” waivers. These waivers would give states the option of allowing insurers to not comply with several aspects of Obamcare, including the requirement that all plans must cover certain “Essential Health Benefits.” Once granted, these waivers can not be rescinded.

• Additional funding for the Community Health Center Fund for 2017. This money comes from the funds that would have gone to Planned Parenthood.

The GOP leadership has posited the Health Care Freedom Act as basically a procedural matter: Something at least 50 Republicans can vote on with the intention of sending the bill to a conference with the House of Representatives, where the finer details would be hashed out before passing a final version on to the White House.

However, Democrats and even some within the Republican party are concerned that this “skinny” bill is nothing but a pretense to get any repeal plan passed as quickly as possible.

Sens. John McCain (AZ), Lindsey Graham (SC), and Ron Johnson (WI) voiced their worries publicly Thursday afternoon, with Graham calling the “skinny” bill a “fraud” if there is no conference and the House GOP passes this bill on a fast-tracked vote.

That concern seemed to have some merit when it later revealed the House Majority Leader Kevin McCarthy (CA) had advised lawmakers in the House that they may have to declare “martial law” on Friday morning, indicating there may be a rushed, immediate vote with no conference.

McCain and his other senators called on Speaker of the House Paul Ryan (WI) to assure them that such a fast-lane vote would not happen, and that the bill would go to conference if it passed the Senate.

Ryan issued a response that acknowledged that sending the bill to conference was a possibility but stopped short of guaranteeing it.

“If moving forward requires a conference committee, that’s something the House is willing to do,” said Ryan in a statement released Thursday evening. “The reality, however, is that repealing and replacing Obamacare still ultimately requires the Senate to produce 51 votes for an actual plan.”

This did not immediately appear to be sufficient for Graham, who said that if he doesn’t receive more concrete assurances from Ryan, he’s a “no” vote.

“I’m not going to vote for a pig in a poke,” said Graham. “I’m not going to vote for a bill that is terrible policy and horrible politics, just because we have to get something done.”

While McCain has called for more definite assurances from the House that they won’t rush to pass the skinny bill — and also gave a stirring speech before his fellow senators on Tuesday, asking for more bipartisan participation on this and other issues — he has voted against multiple efforts by Senate Democrats to send healthcare reform back to committee where a true bipartisan reform of health insurance could be hammered out.

The Congressional Budget Office released a quick score of the “skinny” bill [PDF], effectively repeating its previous prediction that around 16 million additional Americans will end up without insurance as a result of this legislation. Additionally, the CBO estimates that insurance premiums for policies in the individual marketplace will rise by 20% above what the premiums charged under current law.

Insurance premiums are already locked in for the rest of 2017, but insurers will be setting 2018 rates in August. So, if the bill passes as is, we should have some idea of what sort of impact this repeal has on premiums. The effect on enrollment would be seen as that deadline arrives later in the year.

Larry Levitt of the nonpartisan Kaiser Family Foundation reviewed the bill and Tweeted out his views on the “winners” under this legislation: those who will no longer have to pay mandate penalties; makers of medical devices; and large employers who don’t provide insurance coverage to workers. Losers under this proposal would be, according to Levitt, are middle-class families who have to buy their own insurance without the help of subsidies, and now face likely hikes to their insurance premiums.

The American Medical Association, which has repeatedly come out against the repeal effort, did not hold back in its criticism of the “skinny” repeal bill, with AMA President David Barbe, MD, calling it a “toxic prescription that would make matters worse.”

Barbe predicts that the lack of an individual mandate — which insures that healthy Americans pay into the risk pool with the intention of providing care for as many people as possible — would result in higher premiums and further destablize the insurance marketplace.

One of the big sticking points in previous Senate repeal bills was the planned cuts to Medicaid funding. Sens. Susan Collins of Maine and Alaska’s Lisa Murkowski have both openly expressed concern about the impact that such changes would have on their constituents.

The “skinny” bill does not touch Medicaid directly, but there are some who still believe that not only is this legislation prelude to future Medicaid cuts, but that repealing the mandates will still ultimately have a negative impact on Medicaid enrollment, particularly for children.

Joan Alker, the Executive Director of the Center for Children and Families at Georgetown’s Health Policy Institute, wrote on Thursday about what’s known as the “unwelcome mat” effect, the idea that repeal will discourage participation in Medicaid.

Not everyone who is eligible for Medicaid coverage is enrolled in the plan, sometimes because they don’t know they are eligible or feel shame for participating. Alker points out that, even in states where Medicaid was not expanded to cover newly eligible families, there were increases in enrollment in the program from families who were encouraged to research their coverage possibilities and discovered they could receive Medicaid or CHIP benefits for their children.

She points to the huge slash in the number of uninsured children in Nevada in just one year: From an uninsured rate of 15% in 2014 to 7.6% in 2015.

“This is not because children by and large became eligible for something new as a result of the ACA. It is because enrollment in Medicaid for already eligible children went up,” explains Alker. This is the so-called “welcome mat” effect, but, according to Alker, the “skinny” repeal bill could roll out an “unwelcome mat” effect that “will result in fewer children and families having Medicaid coverage because participation rates in Medicaid will start moving in the opposite direction and start going down.”

More to come…

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