The Graham-Cassidy (GC) bill, as proposed on September 13, 2017, threatens to make health care unaffordable and inaccessible for millions of older Americans. The bill eliminates two sources of financial assistance—premium tax credits and cost-sharing reductions—critical to ensuring that low- to moderate-income older adults are able to afford the coverage they need. For a 60-year-old earning $25,000 a year, premiums and out-of-pocket costs could increase by as much as $16,174 a year if they wanted to keep their current coverage. The bill may also allow states to charge older adults age 50–64 significantly higher premiums than under current law on the basis of their age by waiving federal protections that limit the practice known as age rating…..
With only two weeks left to move forward with a partisan health care repeal bill, some Senate Republicans are trying one last time to rip coverage from millions of Americans. Their latest effort, introduced by Sens. Lindsey Graham (R-SC) and Bill Cassidy (R-LA), would make devastating cuts to Medicaid and cut and eventually eliminate funding that helps people in the individual insurance market afford coverage, leading to at least 32 million fewer people having coverage after 2026.
Those who did not lose coverage would see their premiums increase significantly. In the first year, premiums would increase by 20 percent. But the increases would be even greater for people with pre-existing conditions because the bill would let insurers in the individual market charge a premium markup based on health status and history, which could increase their premiums by tens of thousands of dollars…..
From the summary:
The healthcare sector is one of the most important sources of jobs in the economy. Healthcare spending reached $3.2 trillion in 2015 or 17.8 percent of GDP and accounted for 12.8 percent of private sector jobs. It was the only industry that consistently added jobs during the Great Recession. In 2016, the private sector healthcare industry, which is the focus of this report, added 381,000 private sector jobs, the most of any industry. It is a particularly important source of employment for workers without a college degree, most of whom, as we document in this report, earn low wages.
This report describes how organizational restructuring is affecting the job opportunities and wages of healthcare workers. We focus on changing employment and wages in hospitals and outpatient clinics, where the most profound restructuring is occurring. Over the last decade or more, hospitals have restructured the organization of care delivery in response to major technological advances, regulatory changes, and financial pressures. This restructuring has occurred at two levels: the consolidation of hospitals and providers into larger healthcare systems on the one hand; and the decentralization of services and the movement of jobs to outpatient facilities on the other. Outpatient care facilities include a wide range of services — from primary care centers to specialized units such as urgent care centers, ambulatory surgery centers, free-standing emergency rooms, dialysis facilities, trauma and burn units, and other specialty clinics. These organizational changes began before the 2010 passage of the Patient Protection and Affordable Care Act (ACA), but have accelerated considerably since then, and are likely to continue even as the ACA is revamped in the future.
This shift to outpatient care centers offers benefits to patients — convenience as well as opportunities for preventative care — and most healthcare providers and unions have supported the move to more community-based care. But in this report, we show that workers are bearing the costs of this organizational restructuring.
From the summary:
In rolling out their revised bill to repeal the Affordable Care Act (ACA), Senators Bill Cassidy and Lindsey Graham released estimates purporting to show that most states would see large funding gains under their proposal. But these estimates do not compare states’ funding under the proposal to what states would receive under current law, the relevant comparison. Instead, they show how each state’s funding under the proposed block grant would change over time. In reality, the Cassidy-Graham plan would cut federal funding for coverage programs by about $80 billion in 2026 compared to current law, leading to cuts in most states, and would cut federal funding by about $300 billion in 2027, with funding cuts in all states.
In order to win universal health care, we have to understand what — and who — we’re up against. ….
….In health care, private providers and private financing mechanisms were well ensconced long before any meaningful public intervention. The stakes are very high and, historically, a diverse array of private health interests have spent lavishly on political campaigns, and haunted congressional hearings and anterooms. But what has shaped health policy, and stymied reform for the last century, is not so much the combined clout of private interests as it is the tangle of compromise and competition that’s emerged from the scrum as they jockey for influence over policy, for advantage over each other, and for unfettered access to public spending.
Over the last century, the terms of that corporate compromise have been altered through changes in medical care, and changes in the ways medical care is sold, underwritten, packaged, subsidized, regulated, and consumed. The influence of private interests has persisted but, from the first consideration of “health security” in the Progressive Era to the tortuous repeal of the Affordable Care Act over the last few months, which interests have weighed in — or prevailed — has shifted.
Tracing those shifts (sometimes subtle, sometimes profound) is important not just to our understanding of the history, but also to our efforts to win a more just health system…..
Source: Leighton Ku, Erika Steinmetz, Erin Brantley, Nikhil Holla, Brian Bruen, Center for Health Policy Research, Department of Health Policy and Management, Milken Institute School of Public Health, George Washington University, July 2017
From the abstract:
Issue: A draft Better Care Reconciliation Act (BCRA) has been introduced in the U.S. Senate as an alternative to the American Health Care Act (AHCA), which was passed by the House of Representatives on May 4, 2017. The Congressional Budget Office estimates the BCRA would raise the number of uninsured by 22 million by 2026.
Goal: To determine the consequences of the draft BCRA on employment and economic activity in every state. This report updates an earlier analysis of the effects of the AHCA.
Methods: We compute changes in federal spending and revenue from 2018 to 2026 for each state and use the PI+ model to project the effects on states’ employment and economies.
Findings and Conclusions: While the draft BCRA and the AHCA would have similar effects on the number of uninsured Americans, the BCRA would lead to significantly larger job losses and deeper reductions in states’ economies by 2026. A brief spurt in employment would add 753,000 more jobs in 2018, but employment would then deteriorate sharply. By 2026, 1.45 million fewer jobs would exist, compared to levels under the current law. Every state except Hawaii would have fewer jobs and a weaker economy. Employment in health care would be especially hard hit with 919,000 fewer health jobs, but other employment sectors lose jobs too. Gross state products would be $162 billion lower in 2026. States that expanded Medicaid would be especially hard hit.
The American Health Care Act (AHCA) – passed by House Republicans in May, and currently under consideration in the Senate – would dramatically change Medicaid’s financing structure. Currently, Medicaid operates as a federal-state partnership where each pays a percentage of Medicaid’s costs and federal financial support increases with need. Under the per capita cap system proposed in the AHCA, the federal government would provide states with an aggregate amount of funding based on the number and category of eligible beneficiaries in the state, with nominal differences in the amount per beneficiary category. The proposed per capita cap system would adjust for overall population growth, but would not account for other relevant factors affecting Medicaid expenditures, such as changes in health care needs or costs. The Congressional Budget Office estimates that this change in the financing structure along with other changes proposed in the AHCA would cut $834 billion from the Medicaid program. States would likely have to account for the decreased funding by cutting benefits, cutting payments to providers, changing eligibility requirements, and/or adding to program waiting lists.
A per capita cap system would have serious implications for people receiving long-term services and supports (LTSS) – including millions of older adults with functional and cognitive impairments. LTSS include a range of typically non-medical services designed to help individuals perform activities of daily living such as bathing, dressing and eating. Medicaid is the primary payer for LTSS so reductions in Medicaid funds would have serious consequences for people receiving LTSS.
States provide LTSS both in the community and in institutional settings. Per capita caps would cause a shift away from home and community based services (HCBS) toward institutional care such as nursing homes. This is because providing LTSS services through HCBS is optional under Medicaid rules while institutional care is mandatory. HCBS varies by state but generally includes home health services and other services such as adult day care.
This brief provides information on some of the factors that would affect states’ abilities to provide LTSS in a per capita cap system. Additionally, we look at a portion of the labor force that provides LTSS – home health aides and personal care aides specifically – and predict that across the United States, between 305,000 and 713,000 home health aides and personal care aides would lose their jobs if the proposed per capita cap system in the AHCA were to be implemented.
…. The latest development has been the inability of Republicans to even agree on their own proposal and, worse yet, what should come next if it fails. Should they repeal the Affordable Care Act and worry about a replacement later or just try to “fix” the ACA now?
But the problem is much deeper than just a policy fix. As a former health insurance CEO and professor of health finance, it seems clear to me that Republicans are making five key implicit assumptions that are inherently problematic:
1. If it’s your own money, you’ll be more careful in how you’ll spend it. ….
2. Many or most poor people (Medicaid recipients) can work and should contribute to pay for insurance. ….
3. Government restrictions are holding back insurers from competition that would drive costs lower. ….
4. Physicians should be the only ones making care decisions (with the consent of their patients) since they know best. ….
5. Government should help people – but not too much. ….
From the abstract:
Issue: Safety-net hospitals play a vital role in our health care system, delivering significant care to Medicaid, uninsured, and other vulnerable patients. The American Health Care Act (AHCA) would make changes to Medicaid that would substantially reduce federal funding, resulting in potential adverse effects on safety-net hospitals and the populations they serve.
Goal: Examine how the AHCA Medicaid provisions, which the Congressional Budget Office estimates will reduce federal Medicaid spending by $834 billion over 10 years, will affect the financial status of safety-net hospitals.
Methods: The Dobson | DaVanzo Hospital Finance Simulation Model uses Medicare Hospital Cost Report data for 2015 and assumptions regarding how states will respond to the AHCA Medicaid provisions to estimate the financial impact on safety-net hospitals.
Key Findings: Beginning in 2020 the financial status of safety-net hospitals will deteriorate as Medicaid coverage is reduced and the per-capita spending limits proposed in the AHCA grow. By 2026 total margins will drop to 0.5 percent compared with estimates under current law of 2.9 percent—representing an 83 percent reduction in net income for safety-net hospitals. Small rural safety-net hospitals and safety-net hospitals treating the largest proportion of low-income patients would be hurt the most.
….The Center for American Progress has estimated how many Americans would lose coverage by state and congressional district based on the CBO’s projections. By 2026, on average, about 50,500 fewer people will have coverage in each congressional district. Table 1 provides estimates by state, and a spreadsheet of estimates by state and district can be downloaded at the end of this column…..
H.R. 1628, Better Care Reconciliation Act of 2017
Source: Congressional Budget Office, Cost Estimate, no. 52849, June 26, 2017
From the summary:
CBO and JCT estimate that enacting the Better Care Reconciliation Act of 2017 would reduce federal deficits by $321 billion over the coming decade and increase the number of people who are uninsured by 22 million in 2026 relative to current law.