[Senate Hearing 115-377]
[From the U.S. Government Publishing Office]
S. Hrg. 115-377
GRAHAM-CASSIDY-HELLER-JOHNSON PROPOSAL
=======================================================================
HEARING
before the
COMMITTEE ON FINANCE
UNITED STATES SENATE
ONE HUNDRED FIFTEENTH CONGRESS
FIRST SESSION
__________
SEPTEMBER 25, 2017
__________
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Printed for the use of the Committee on Finance
_________
U.S. GOVERNMENT PUBLISHING OFFICE
32-664 PDF WASHINGTON : 2018
COMMITTEE ON FINANCE
ORRIN G. HATCH, Utah, Chairman
CHUCK GRASSLEY, Iowa RON WYDEN, Oregon
MIKE CRAPO, Idaho DEBBIE STABENOW, Michigan
PAT ROBERTS, Kansas MARIA CANTWELL, Washington
MICHAEL B. ENZI, Wyoming BILL NELSON, Florida
JOHN CORNYN, Texas ROBERT MENENDEZ, New Jersey
JOHN THUNE, South Dakota THOMAS R. CARPER, Delaware
RICHARD BURR, North Carolina BENJAMIN L. CARDIN, Maryland
JOHNNY ISAKSON, Georgia SHERROD BROWN, Ohio
ROB PORTMAN, Ohio MICHAEL F. BENNET, Colorado
PATRICK J. TOOMEY, Pennsylvania ROBERT P. CASEY, Jr., Pennsylvania
DEAN HELLER, Nevada MARK R. WARNER, Virginia
TIM SCOTT, South Carolina CLAIRE McCASKILL, Missouri
BILL CASSIDY, Louisiana
A. Jay Khosla, Staff Director
Joshua Sheinkman, Democratic Staff Director
(ii)
C O N T E N T S
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OPENING STATEMENTS
Page
Hatch, Hon. Orrin G., a U.S. Senator from Utah, chairman,
Committee on Finance........................................... 1
Wyden, Hon. Ron, a U.S. Senator from Oregon...................... 4
CONGRESSIONAL WITNESSES
Graham, Hon. Lindsey, a U.S. Senator from South Carolina......... 7
Hirono, Hon. Mazie K., a U.S. Senator from Hawaii................ 10
WITNESSES
Cassidy, Hon. Bill, M.D., a U.S. Senator from Louisiana.......... 13
Santorum, Hon. Rick, a former U.S. Senator from Pennsylvania..... 15
Smith, Dennis G., Senior Advisor for Medicaid and Health Care
Reform, Arkansas Department of Human Services, Little Rock, AR. 17
Miller, Teresa, Acting Secretary, Department of Human Services,
Commonwealth of Pennsylvania, Harrisburg, PA................... 19
Mann, Cindy, former Deputy Administrator and Director of the
Center for Medicaid and CHIP Services, Centers for Medicare and
Medicaid Services, Department of Health and Human Services,
Washington, DC................................................. 21
Woodruff, Dick, senior vice president of Federal advocacy,
American Cancer Society Cancer Action Network, Washington, DC.. 23
ALPHABETICAL LISTING AND APPENDIX MATERIAL
Bennet, Hon. Michael F.:
Kaiser Family Foundation study projections for Colorado under
the
Graham-Cassidy proposal.................................... 91
Cassidy, Hon. Bill, M.D.:
Testimony.................................................... 13
Prepared statement........................................... 93
Responses to questions from committee members................ 94
Graham, Hon. Lindsey:
Testimony.................................................... 7
Prepared statement........................................... 99
Hatch, Hon. Orrin G.:
Opening statement............................................ 1
Prepared statement........................................... 100
Hirono, Hon. Mazie K.:
Testimony.................................................... 10
Prepared statement........................................... 101
Mann, Cindy:
Testimony.................................................... 21
Prepared statement........................................... 101
Responses to questions from committee members................ 115
Miller, Teresa:
Testimony.................................................... 19
Prepared statement........................................... 127
Responses to questions from committee members................ 131
Santorum, Hon. Rick:
Testimony.................................................... 15
Prepared statement........................................... 136
Response to a question from Senator Brown.................... 138
Smith, Dennis G.:
Testimony.................................................... 17
Prepared statement........................................... 138
Woodruff, Dick:
Testimony.................................................... 23
Prepared statement........................................... 142
Responses to questions from committee members................ 145
Wyden, Hon. Ron:
Opening statement............................................ 4
Prepared statement with attachments.......................... 147
Communications
Adams, Marilyn................................................... 153
Alliance of Community Health Plans (ACHP)........................ 153
The ALS Association.............................................. 154
ALS Association et al............................................ 155
American Academy of Family Physicians (AAFP)..................... 156
American Cancer Society Cancer Action Network (ACS CAN).......... 159
American Civil Liberties Union (ACLU)............................ 160
American College of Emergency Physicians (ACEP).................. 162
American College of Physicians (ACP)............................. 162
American Diabetes Association.................................... 166
American Heart Association....................................... 167
American Hospital Association (AHA).............................. 170
American Lung Association........................................ 172
American Nurses Association (ANA)................................ 177
American Thoracic Society (ATS).................................. 181
America's Health Insurance Plans (AHIP) and Blue Cross Blue
Shield Association (BCBSA)..................................... 182
The Arc of Colorado.............................................. 188
The Arc of Massachusetts......................................... 189
The Arc of New Jersey............................................ 190
The Arc of Pennsylvania.......................................... 191
The Arc Tennessee................................................ 193
The Arc of the United States..................................... 194
The Arc Wisconsin................................................ 195
Arthritis Foundation............................................. 197
Association of Maternal and Child Health Programs................ 198
Beck, Kristine................................................... 199
Blue Shield of California........................................ 199
Blue Cross Blue Shield of Massachusetts (BCBSMA)................. 200
Brain Injury Association of America.............................. 202
Brininger, Ruth Hong............................................. 203
Bruner, Charles, Ph.D............................................ 203
Cahill, Anne..................................................... 204
Center for Fiscal Equity......................................... 205
Children's Hospital Association.................................. 206
Consortium for Citizens With Disabilities........................ 207
Crawford, Arlene J............................................... 210
Cystic Fibrosis Foundation....................................... 211
Disability Rights California (DRC)............................... 213
Disability Rights Ohio (DRO)..................................... 215
Disability Rights Wisconsin (DRW)................................ 217
Doctors Organized for Healthcare Solutions....................... 220
Family Voices.................................................... 241
Feminist Majority................................................ 242
Fox, Sarah, Ph.D................................................. 246
Friday Health Plans.............................................. 248
Giroux, Anne Morgan.............................................. 249
Guttmacher Institute............................................. 250
Hadden, Sue Matthes, R.N......................................... 253
Holland, Carolyn................................................. 253
Holmberg, Marion................................................. 254
Jaber, Samir S................................................... 254
The Jewish Federations of North America (JFNA)................... 256
LeadingAge....................................................... 258
Little Lobbyists................................................. 261
Lusk, Don and Laurine............................................ 267
March of Dimes Foundation........................................ 269
The Michael J. Fox Foundation for Parkinson's Research........... 271
Michigan Developmental Disabilities Council...................... 273
NARAL Pro-Choice America......................................... 275
National Association of School Nurses (NASN)..................... 276
National Council for Behavioral Health........................... 277
National Disability Rights Network (NDRN)........................ 278
National Health Council (NHC).................................... 280
National Health Law Program...................................... 282
National Multiple Sclerosis Society.............................. 288
National Partnership for Women and Families...................... 289
National Women's Law Center...................................... 290
Oklahoma Council of the Blind (OCB).............................. 295
Papadopoulos, Lecia.............................................. 296
The Partnership for Medicaid..................................... 300
Prevent Blindness................................................ 301
Prochnow, Brenda................................................. 302
Resource Center for Accessible Living, Inc. (RCAL)............... 303
Shiffrin, Eva.................................................... 304
Sorensen, Barbara Burke.......................................... 305
Statewide Parent Advocacy Network (SPAN) and Family Voices-New
Jersey......................................................... 306
Steen, Shawn M................................................... 308
Thomas, Earline.................................................. 309
Todebush, Emily.................................................. 310
Trust for America's Health....................................... 311
UnidosUS......................................................... 320
Wallace, Laura................................................... 324
Wisconsin Board for People With Developmental Disabilities....... 325
Wisconsin Family Ties............................................ 327
Wurzbach, Deanna................................................. 328
Zaremski, Miles J., Esq.......................................... 329
Zarske, Ginger................................................... 330
Zusman, Miriam and Neil.......................................... 330
GRAHAM-CASSIDY-HELLER-JOHNSON PROPOSAL
----------
MONDAY, SEPTEMBER 25, 2017
U.S. Senate,
Committee on Finance,
Washington, DC.
The hearing was convened, pursuant to notice, at 2 p.m., in
room SD-215, Dirksen Senate Office Building, Hon. Orrin G.
Hatch (chairman of the committee) presiding.
Present: Senators Grassley, Roberts, Enzi, Thune, Isakson,
Portman, Toomey, Heller, Scott, Cassidy, Wyden, Stabenow,
Cantwell, Nelson, Carper, Cardin, Brown, Bennet, Casey, Warner,
and McCaskill.
Also Present: Republican Staff: Jay Khosla, Staff Director;
Jennifer Kuskowski, Chief Health Policy Director; Preston
Rutledge, Senior Tax and Benefits Counsel; Jeff Wrase, Chief
Economist; and Martin Pippins, Detailee. Democratic Staff:
Joshua Sheinkman, Staff Director; Anne Dwyer, Senior Health
Counsel; Michael Evans, General Counsel; Elizabeth Jurinka,
Chief Health Policy Advisor; and Arielle Woronoff, Senior
Health Counsel.
OPENING STATEMENT OF HON. ORRIN G. HATCH, A U.S. SENATOR FROM
UTAH, CHAIRMAN, COMMITTEE ON FINANCE
The Chairman. The committee will come to order. I would
like to welcome everyone, and I do mean everyone.
[Interruption from the audience.]
The Chairman. If you want a hearing--if you want a hearing,
you had better shut up.
Okay, let us get----
Senator Grassley. Let the police take care of it. Just let
the police take care of it.
The Chairman. Oh, I will. I will.
All right.
[Interruption from the audience.]
The Chairman. Get the police in here.
[Interruption from the audience.]
Senator Grassley. Do you want to stand in recess until they
get them out of here?
The Chairman. Let us give them a little more time. Let us
let them get it out of their system.
[Interruption from the audience.]
The Chairman. I think I had better recess here for a few
minutes. Is that okay with you?
Senator Wyden. It is your call.
The Chairman. I do not see sitting through this much
longer.
Okay, the committee is in recess. The committee will be in
recess until we get order.
[Whereupon, the committee was recessed at 2:09 p.m.,
reconvening at 2:17 p.m.]
The Chairman. Let us have order. And let us show some
respect here. Look, a lot of us are on your side, so let us
have some order. If you cannot be in order, then get the heck
out of here.
Okay, the committee will come to order.
I would like to welcome everyone to this afternoon's
hearing where we will discuss and examine the Graham-Cassidy-
Johnson-Heller health-care proposal.
Given the relatively unique circumstances we are facing
with regard to health care generally, and this proposal in
particular, the Senate Republican leadership as well as members
of the conference have asked for a hearing on this proposal so
that we can all get a better sense of how it is intended to
work.
Toward that end, we have two distinguished panels of
witnesses before us today. The first panel will feature
statements from two of our distinguished Senate colleagues.
[Interruption from the audience.]
The Chairman. If the police would please remove that
person, we would appreciate it. And keep the doors shut.
Okay. The second panel will feature another one of our
colleagues who is also a member of this committee. We will hear
from a friend and former Senate colleague on the second panel
as well.
Joining them at the table will be experts and stakeholders
who are here to share their views on the proposal from Senators
Graham, Cassidy, Heller, and Johnson.
The purpose of the hearing is to respectfully discuss ideas
and become better informed on particular issues.
[Interruption from the audience.]
The Chairman. The purpose of the hearing, as I have said,
is to respectfully discuss ideas and become better informed on
particular issues. It does not mean that everyone shares the
same views and opinions. In fact, I expect that quite a few
disagreements will be expressed today, and that is okay with
me. I have been in the Senate for 4 decades now and in that
time have been a part of some very difficult and contentious
debates.
Early on, I was part of a fierce debate over labor law
reform. Over the years, I have participated in some of the most
heated Supreme Court hearings in our Nation's history. I was
here to take part in drafting, debating, and passing the
Americans with Disabilities Act, one of my proudest
accomplishments.
I was around when the debate over the war in Iraq became
extremely combative. And of course, I was here when we debated
Obamacare before it passed. And I have been here for every
debate we have had about it since that time.
So I have been through an awful lot of this. And it is
nothing new to me. So I understand that there are some strong
opinions about this issue. And more importantly, I understand
why opinions are so strong.
When we talk about health-care policy, we are not just
talking about a theoretical concept or legislation that impacts
a single isolated industry. This topic has a significant impact
on the lives of every person in this country in ways that can
make or break both their health and their livelihoods.
Frankly, because this issue is so personal, everyone has
strong feelings on all sides of these issues.
[Interruption from the audience.]
The Chairman. If we could shut that door and keep it shut,
I would appreciate it.
To members of the committee, to those in the audience
today, and to any person who may watch or read about today's
hearing at some point in the future, let me say this: I respect
your opinions on these issues, but, while I wish that
expressions of good will could on their own fix our Nation's
problems, that is just not the case. We have to do the work.
And on these issues, the work is particularly hard.
Today we are here to discuss the most recent health-care
proposal drafted by some of our colleagues. And I commend them
for their efforts and their willingness to put forward ideas to
address these very difficult problems.
My hope is that we can spend our time today questioning our
witnesses about substance and policy, not on scoring political
points, particularly when we have distinguished colleagues and
a former colleague at the witness table.
I know that for both sides of this debate, passionate
demonstrations and righteous indignation, particularly when
there are cameras in the room, make good fodder for Twitter and
TV commercials, especially when the subject is health care.
Our committee is generally regarded as being above such
shenanigans, though we have not been entirely immune to these
types of theatrics in the past.
For today, let me just say this: if the hearing is going to
devolve into a sideshow or a forum simply for putting partisan
points on the board, there is absolutely no reason for us to be
here.
I will not hesitate to adjourn the hearing if it gets to
that point. It has not gotten there yet, but it is close. I am
saying this for the benefit of my colleagues on the committee
and everyone in the audience. Let us have a civil discussion.
I have no objection to having a spirited debate on these
issues. My gosh, I was the author of the Americans with
Disabilities Act, so I have very deep feelings about these
issues, and I think most here on this committee have deep
feelings as well.
My hope is that, in the end, our efforts will generate more
light and less heat than we have seen in the most recent
episodes of the health-care debate. If we cannot have that, we
should all be spending our time on something more productive.
So with that and those few remarks, I now turn to our
ranking member, Senator Wyden, for his remarks.
[The prepared statement of Chairman Hatch appears in the
appendix.]
OPENING STATEMENT OF HON. RON WYDEN,
A U.S. SENATOR FROM OREGON
Senator Wyden. Thank you very much, Mr. Chairman.
Mr. Chairman, I have an opening statement, and then at the
conclusion of that, I would like to bring up several points
about the process. And I understand we have agreed to that.
The Chairman. That would be fine.
Senator Wyden. Colleagues, nobody has to buy a lemon just
because it is the last car on the lot. This Trumpcare bill is a
health-care lemon, a disaster in the making. The fact that it
is the last Republican repeal bill standing does not make it
okay. It is going to be a nightmare for tens of millions of
Americans, and it makes a mockery of the President's promise of
better insurance for everybody at lower costs.
The bill's sponsors are not even waiting for the official
facts and figures from the independent scorekeepers. Version
after version of this bill is floating around, and the pork
parade is up and running. The process that has brought this
Trumpcare bill to the brink of passage would be laughable if
the well-being of tens of millions of Americans was not in the
balance.
Now, I want to blow the whistle on a few key points at the
outset. First off, the American people do not want this bill.
In the last few days, the committee has received more than
25,000 comments from people who want it stopped. As with every
other version of Trumpcare, this proposal is about as popular
as prolonged root canal work.
There is one group cheering the bill on: the right-wing
Republican donor class. The big donors want the entire
Affordable Care Act thrown in the trash, and they have wanted
it from the beginning. But it did not work, since it turns out
that it is bad policy to take health coverage away from tens of
millions of Americans and raise costs for virtually everybody
else.
So the new strategy is essentially repeal by a thousand
cuts. It would be national repeal, and it would be State-by-
State repeal. The heart of this bill is a scheme that punishes
the States that have worked hard to build strong private
markets and make health care more affordable. It rewards the
States where lawmakers have sat on their hands, where they have
spent years loudly rejecting the opportunity to improve the
lives of millions of the people they serve.
But that is not a proposition that gets much support. So
instead, the committee today is going to hear a lot of hocus-
pocus about the word ``flexibility.''
The story goes, it is flexibility for the States, more
control at the local level, and somehow everybody by osmosis is
going to be better off.
But let's be up-front about what it means in practice. The
real flexibility created by the bill is the option for States
to do worse so that Americans are forced to pay more for less
care.
Now, off the top, this version of Trumpcare guts funding
for health care in the new block grants. Then Governors and
State legislators build new health insurance systems, and they
are basically going to have to make ``Hunger Games'' choices,
deciding which vulnerable people get care and which do not.
The iron-clad, loophole-free, guaranteed protection for
those with preexisting conditions will be gone. The bill's
sponsors will tell you otherwise, but, colleagues, the facts
are the facts. The guaranteed protection that nobody will be
gouged due to a catastrophic illness, like cancer, will be
done. That is because the bill reopens the door to annual and
lifetime limits on care.
The guarantee of essential benefits--gone. That means
prescription drug coverage is on the chopping block. Maternity
care, on the chopping block. Mental health and substance abuse
treatment, on the chopping block. And a whole lot more. The
guarantee that nobody could be charged higher premiums because
of their health status or their job, also gone.
Bottom line: this bill is an all-out assault on vital
consumer protection. It revives some of the worst insurance
company abuses that were banned under the Affordable Care Act,
and it is going to make the health care that many people need
unaffordable. No, it does not adequately protect people with
preexisting conditions.
What the bill does include are a few toothless lines about
affordability and access. That is supposed to be protection,
real protection for people with preexisting conditions. But
there is no enforcement mechanism, no tough standards, no real
definitions. And the
watered-down protection States put together for new insurance
systems then can get a rubber stamp from team Trump.
Once again, in the Trumpcare bill there is an attack on
women's health. Hundreds of thousands of women are going to
lose the right to see the doctor of their choice. That is what
you get when you defund Planned Parenthood.
The traditional Medicaid program, a lifeline for people
with disabilities, seniors, kids, and pregnant women--draconian
cuts.
An aging baby boomer who suffered a stroke might not get
the help they need. The guarantee of nursing home care will not
be there. The community-based program that offers care to
people at home where they are most comfortable could disappear.
Special education programs funded by Medicaid for vulnerable
kids could be put in jeopardy.
A few closing points, Mr. Chairman.
The process that has led to this moment has been an
abomination. And we have just seen, colleagues, some of the
frustration that our people have at closed-door government that
locks Americans out of the democratic process. This just is not
serious--it is really a talking point today. It is a scheme to
let Senators go home to fearful constituents and offer
assurances, false assurances, that this bill got a fair
examination and went through the regular order. It is not true.
Senate Republicans have not gotten answers to the most
basic questions about the real-world effects of the bill. How
many people are going to lose coverage? By how much are
premiums going to increase? Will the health-care market survive
next year?
The independent scorekeepers at the Budget Office say it is
going to be several weeks before they can put forward estimates
of coverage and cost. And their job gets tougher because this
bill just changes by the hour as the majority throws around in
the scramble for votes.
Why the rush job? It is because the coach turns back into a
pumpkin at the end of the month. That is when the
reconciliation fast-track to pass the partisan bill expires.
Now, we want to be clear. On this side, we think we ought
to be working on bipartisan priorities. We have a good bill for
kids, the Children's Health Insurance Plan, which covers 9
million kids. The funding for that program, colleagues, runs
out in just a few days at the end of the month. We would like
to be working on that in a bipartisan way.
And we would like to be working on stabilizing the private
insurance markets. I heard about that this weekend in town hall
meetings in central Oregon. That is what we want to work on. We
want to do it in a bipartisan way with our sister Senate
committee.
Instead, what is on offer is this Trumpcare bill that is
going to trigger a health-care disaster, a death spiral in the
insurance markets as tax credits and cost-sharing payments go
away, healthy people flee, and costs go into the stratosphere.
Democrats on this side of the dais want to continue to do
everything, (1) to stop this dreadful proposal from becoming
law, and (2) to get down to the serious heavy lifting of
passing bipartisan legislation for kids, number one, and for
adults in the individual insurance market.
Now, with that, Mr. Chairman, I would like to just wrap up
with a few quick points about procedure for this hearing. This
is per our agreement.
First, Mr. Chairman, I think you know that we are very
disappointed in the response to our request to hold this
hearing in a larger room that could accommodate more members of
the public.
I would ask unanimous consent that a letter outlining this
request be included in the record.
The Chairman. Without objection.
[The letter appears in the appendix on p. 149.]
Senator Wyden. This is the first and only hearing that will
be held regarding a bill affecting more than 320 million
Americans and one-sixth of our economy. As we just saw, there
is enormous public interest.
We have seen hundreds of people today, many in wheelchairs,
lined up in the hall hoping to get into the hearing. However,
after you take account of the committee members, staff,
witnesses, and members of the press, the room we are in only
has space for about 30 members of the public--30 for a hearing
of this import.
Normally when Congress holds hearings that attract such
enormous public attention, we have our hearings in the largest
hearing rooms to accommodate hundreds of audience members. My
understanding is, those rooms are available today. So the
question I really have is, why not move the hearing there,
somewhere people can attend? Otherwise, it sends yet one more
signal that the majority wants to keep the bill under wraps
rather than opening up the process to the American people.
Finally, Mr. Chairman, I understand that Senator Cassidy
wants to participate in this hearing both as a witness
providing testimony and as a member of the committee asking
questions of the same witness panel he is part of.
I expect we are going to hear a lot today from Senator
Cassidy about flexibility. I gather he is a big fan of
flexibility. He appreciates flexibility so much, he wants to
apply it to himself.
However, to my mind, dashing back and forth between the
witness table and the dais is not proper decorum for a hearing.
So I would just like to make that clear, Mr. Chairman, because
my understanding with respect to the rules is, I have to leave
it at that.
I sure think it is more appropriate that Senator Cassidy
wears one hat during this hearing rather than two.
Thank you.
[The prepared statement of Senator Wyden appears in the
appendix.]
The Chairman. Well, thank you, Senator. I think Senator
Cassidy ought to be able to do what he wants to do. But I will
make sure he does not ask questions of himself. [Laughter.]
Senator Wyden. Interesting.
The Chairman. Well, maybe I had better withdraw that.
[Laughter.]
I appreciate your kind and good remarks.
Now, because of the high interest and the importance of
this hearing, an overflow room has already been secured, not to
mention it will be televised on C-SPAN and available for live
streaming on the Senate Finance Committee website.
To my colleagues' complaints about the process for setting
up this hearing, I will just say that many Senators have
expressed a desire to examine details of the proposal we are
discussing today. Today's hearing is being held to allow
members on both sides to delve deeper into the policy and gain
a better understanding of what our colleague's proposal hopes
to achieve. I do not expect this hearing to go on forever, but
we will get, certainly, good opportunity.
Now, I would like to welcome each of our witnesses to our
hearing today.
To start off, on the first panel we will hear from our good
friends and fellow Senators, the senior Senator from South
Carolina, Lindsey Graham, who is the coauthor of this bill, and
the junior Senator from Hawaii, Mazie Hirono, for opening
remarks.
We are grateful to have such passionate and wonderful
Senators join us today to share their views.
Senator Graham, will you please share with us your remarks,
and then we will go to Senator Hirono?
STATEMENT OF HON. LINDSEY GRAHAM,
A U.S. SENATOR FROM SOUTH CAROLINA
Senator Graham. Thank you, Mr. Chairman.
The first remark I would like to share with you is why I am
here. I am here because Obamacare is a disaster in my State. It
is not your job to take care of South Carolina; it is mine, and
I intend to do that. Maybe we will find a common way forward, I
do not know, but I am not going to be deterred.
The Chairman. But I intend to help--put it that way.
Senator Graham. Thank you. In 2014, there were five
insurers offering plans to South Carolina customers under the
exchange. Today we are down to one with a 31-percent increase
announced Friday. If you expect me to walk away from that, you
are sadly mistaken.
I do not know how it is working in your State, but in my
State it is a disaster.
Why are we in Finance? Because health care really does
affect Federal finances. Most of you know that by 2042 that the
entire revenue stream will be consumed by Medicare and Medicaid
spending unless somebody does something about it. There will be
no money for the military, the Department of Education, NIH, or
anything else.
So what do I do? I deal with two problems. Nationally,
Obamacare premiums are going up 13 percent in the individual
market, 45 percent of the counties in America are down to one
choice, and 45 counties in this country have no choice under
the plan you designed.
The bottom line is, I do not doubt your intention to help
people; I do question whether or not it is working as intended.
And you can question my motives, and, quite frankly, I do not
care, because I know why I am here.
The Chairman. You are saying who designed it? It was not
mine, I will tell you that.
Senator Graham. Well, I know, Mr. Chairman, it was not. So
we have two problems. If somebody does not fix Obamacare soon,
the majority of counties in this country are going to be down
to one provider. It is collapsing as I speak.
Medicaid--Medicaid is on an unsustainable path. By 2027, we
are going to be spending more on Medicaid than the military. By
2042, Medicare and Medicaid combined take all the money that is
going to be sent to Washington in taxes. And what do we do?
In Year 8 of the block grant, we give flexibility and
control to the States over the Medicaid program like they have
not had before, but they have to spend it on the population in
question. We begin to slow the growth down to make it more
sustainable. But the flexibility we give will allow us to get
better outcomes. Medicaid spending and Medicaid outcomes are
not matched up where anybody should want them to be.
When it comes to Obamacare, if you do not find a way to
stop the bleeding, then it is going to basically collapse
before our eyes.
And here is what we do. I am getting a lot of pushback from
my Republican colleagues because I leave the taxes in place.
Here is the idea of Graham-Cassidy-Heller-Johnson. We repeal
the individual mandate and the employer mandate, but you can
reimpose it in your State if you like.
If you want to go to single-payer health care, you can do
it in Oregon, but you are not going to drag me with you.
So here is the deal. We leave the taxes in place, that is
$1.2 trillion, and we block-grant it out to the States in a
formula that I think is fair. Under Obamacare, between 2020 and
2026, four States get 35.4 percent of the money. They are
Maryland, Massachusetts, New York, and California, and they are
22 percent of the population. Good deal for them; not so much
for the rest of us. Under this block grant, they get 29
percent, not 35--still more than the population.
What have I learned? Hawaii is a very expensive place to
provide Medicaid. It is a very expensive place to provide
health care. It is just a very expensive place to live.
Alaska has 750,000 people and is 2\1/2\ times the size of
Texas. Under this bill, we look at you. Rather than some
bureaucrat in Washington who has all the money and the power,
we are going to turn it back to you, your State legislature and
your Governor.
And I asked the following question at a lunch not long ago.
How many of you know your State House member? Almost everybody
raised their hands. How many of you know the Governor of South
Carolina? Everybody raised their hand. I asked the question,
how many of you know who is in charge of Obamacare in South
Carolina? Nobody raised their hand. And that is the problem.
We are going to send this money back to the States. You
cannot spend it on roads and bridges; you have to spend it on
health care. You are going to have flexibility, but you are
also going to have accountability. And for the first time in
health care, somebody is going to listen to you. Because if you
do not like the health care you have, you can complain to
somebody you vote for: ``The model you have created is never
going to work.''
As to the opposition to this bill, to the ranking member,
every major insurance company opposes our bill. Why? Because we
take hundreds of billions of dollars away from them, that were
going to them from the Federal Government, and give it to the
States. Guess what? They do not like that.
If I were a major insurance company, I would hate my bill,
because I take money and power away from you and I give it to
the States.
Washington is wired when it comes to health care. Everybody
opposing this bill is a big winner of Obamacare. And my goal is
to get the money and power out of Washington, closer to where
people live so they will have a voice about the most important
thing in their life.
I do not need a lecture from anybody about health care, but
what you have created is not working. It is time to try
something new. And I believe with all my heart and soul, Mr.
Chairman, that if we took the money and power out of Washington
and we got it closer to the patient, we put it in the hands of
somebody you would have a relationship with and you could
actually vote for if you do not like the product, we are going
to get a better outcome. And this is not the last chance, this
is the best chance.
And to my friends to the left, I will do everything I can
to stop and put a stake in the heart of single-payer health
care. You do not like Obamacare, you do not think it is big-
government enough; I am here to stop you. You care as much as I
do about health care, but going beyond Obamacare is a nightmare
for this country. It will ruin health care and bankrupt the
American people.
And this is a debate worth having. Thank you very much. God
bless you all.
The Chairman. Well, thank you, Senator Graham.
[The prepared statement of Senator Graham appears in the
appendix.]
The Chairman. Senator Hirono, please proceed with your
statement now.
STATEMENT OF HON. MAZIE K. HIRONO,
A U.S. SENATOR FROM HAWAII
Senator Hirono. Thank you, Mr. Chairman, Ranking Member
Wyden, and all of the members of the committee. Thank you for
inviting me to testify.
When I was diagnosed with stage 4 kidney cancer about 5
months ago--two things. The first was the diagnosis came as a
total shock to me. It came about incidental to a physical
checkup that involved an entirely different procedure that I
was facing. This is how a lot of people learn about a serious
illness or condition, out of the blue, bang. You cannot plan
for it.
Second, I received letters, cards, and notes when people
found out. I was touched by the hands reaching out to me, the
show of compassion, including from so many of my colleagues,
including members of this committee on both sides of the aisle.
Every day now, people come up to me at airports, grocery
stores, restaurants to tell me that they too are cancer
survivors. There is a connection there.
It is never a good time to have cancer. But what I am
experiencing through my cancer is the care and concern
expressed by total strangers. This is compassion. It helps me a
lot.
What we do as leaders affecting everyone's lives should
reflect compassion. Sadly, that is not in this bill. In the
greatest, richest country in the world, compassion for our
fellow men and women should not be so elusive or indeed
missing.
After all the compassion and care that I received from my
colleagues after I disclosed my diagnosis, the Graham-Cassidy
proposal reflects neither care nor compassion for millions
across the country.
Health care is a right. It is a right. It is not a
privilege reserved for those who can afford it. But Graham-
Cassidy treats health care like a commodity that can be bought
and sold. This is fundamentally wrong.
Although nearly all of us will face a serious illness
during our lifetimes, it is almost impossible to budget and
plan for the costs associated with treating it. And once you
are diagnosed, you cannot just put off treatment because you
cannot afford it.
Before the Affordable Care Act, catastrophic health-care
costs were the largest driver of personal bankruptcies in the
country. And since the law went into effect, we have seen a
huge reduction in personal bankruptcies. There is a causal
relationship when people get health care.
If you dig into the details and numbers, it is clear this
bill is much worse than the bill we defeated in July. Under the
thin veneer of States' rights and local control, the Graham-
Cassidy bill imposes a radical overhaul on one-sixth of the
American economy.
According to the Brookings Institution, 32 million people
will lose their health coverage under it. There is so much
wrong with this bill that it is difficult to confine my remarks
to only the short time I have been allowed to testify.
Contrary to promises made by the bill's authors, this
proposal undermines protections for the close to 600,000 people
in Hawaii and 134 million people all across the country living
with preexisting conditions. This bill seriously undermines
consumer protections that require coverage for preexisting
conditions and prohibit insurance companies from charging sick
people more for care, which is exactly what they will do,
believe me, if this bill passes.
The process requires a pro forma explanation of how a State
would maintain coverage for those with preexisting conditions.
But it is really a box that they just check off. There is
nothing here that ensures the level of protection that the
Affordable Care Act does.
Sure, the Federal Government can deny a State's waiver
application, but the very people who would be making this
decision at the Federal level are longtime opponents of the
Affordable Care Act. Sadly, the American people cannot trust
this administration to do the right thing regarding their
health care.
We do not have to look back far to see what the result
would be of a State-granted waiver. Insurance companies could
use age, health status, and other factors to determine what
premiums to charge. They could set annual and lifetime limits
on care and could refuse treatments because of how much they
cost.
Believe me, I have a complicated illness, and I would reach
lifetime limits in practically a nanosecond. I intend to live a
lot longer before that day comes. Under this bill, coverage
might be available, but it would be prohibitively expensive and
able to be taken away in someone's moment of greatest need.
This bill dismantles Medicaid as we know it. The bill
converts Medicaid into a block grant to States and cuts its
funding by hundreds of billions of dollars by 2026. It punishes
States like Hawaii that expanded Medicaid by cutting Federal
funding and redistributing it to those States that did not
expand Medicaid; and therefore, hundreds of thousands of people
in those States do not even have the kind of coverage that
Hawaii provided.
For Hawaii, we are looking at around $4 billion in cuts and
91,000 fewer Hawaii residents having health care because of
this bill.
Because States would receive so much less money, they will
no longer be able to provide quality, adequate care for as many
people as possible. Instead, they will face the impossible task
of choosing who should lose insurance and which services to
cut. Even then, the most vulnerable members of our society, the
elderly and the disabled and children, will not receive the
care and services they need.
Mr. Chairman, we are all one diagnosis away from a major
illness. I have certainly found that out. With so much
uncertainty right now in our country, the one thing that people
should be able to count on in the richest country in the world
is getting the care they need when they need it.
Health care is a right, not a privilege for those who can
afford it. Health care is personal to every single one of us.
I would like to conclude with a call to action. This bill
would be devastating for millions of people across the country
facing dire health consequences. Millions of lives are at
stake. Let us return to the bipartisan negotiations led by
Senators Alexander and Murray to stabilize the health insurance
marketplace. This is something they are doing together in a
bipartisan way.
This is exactly how we should approach health care in our
country. Focus on the people we are elected to serve. Focus on
the people we are elected to serve. Show them the compassion
that they are expecting from their leaders. They expect us to
work together and come up with a bill that we can get behind.
Thank you, Mr. Chairman.
The Chairman. Well, thank you, Senator Hirono. We
appreciate your remarks.
[The prepared statement of Senator Hirono appears in the
appendix.]
The Chairman. Thanks to both of you for sharing your
remarks to the committee today.
I think I speak for all of my colleagues when I say that we
are hopeful and praying, Senator Hirono, for your quick and
total recovery from cancer.
We do appreciate both of you for taking the time to be with
us today. You are both welcome to stay for as long as you wish.
Now we are going to turn to panel two. Next, we will hear
from the six witnesses that sit before the committee today. I
will introduce witnesses briefly and then have each of you
provide your testimony in the order you are introduced.
First, we will hear from a good friend, colleague, and
fellow committee member, the Honorable Dr. Bill Cassidy. Prior
to his coming to the Hill in 2015, Senator Cassidy provided
care for uninsured and underinsured patients for nearly 30
years.
He is a co-founder of the Greater Baton Rouge Community
Clinic, created a private/public partnership to vaccinate
children against Hepatitis B, and in the wake of Hurricane
Katrina he led a group of health-care volunteers to convert an
abandoned K-Mart building into an emergency health-care
facility.
Senator Cassidy has also taught at the LSU medical school
and is a former member of both the Louisiana State Senate and
the U.S. House of Representatives. Senator Cassidy attended the
Louisiana State University for both his undergraduate and
medical degrees.
Secondly, we will hear from our good friend and former
colleague Senator Rick Santorum. Former Senator Santorum served
in the U.S. Senate from 1995 to 2007, prior to which he also
served in the U.S. House of Representatives from 1991 to 1995.
Senator Santorum and his wife, Karen, are also coauthors of
the bestselling book ``Bella's Gift: How One Little Girl
Transformed Our Family and Inspired a Nation.''
Senator Santorum received his bachelor's degree from Penn
State University, his M.B.A. from the University of Pittsburgh,
and his law degree from Dickinson School of Law.
Next we will hear from Mr. Dennis G. Smith, the Senior
Adviser for Medicaid and Health Care Reform at the Arkansas
Department of Human Services and a visiting professor at the
University of Arkansas Medical Sciences College of Public
Health.
Mr. Smith has spent most of his career in public service.
At the Federal level, he has worked in both the executive and
legislative branches, including 10 years on Capitol Hill and 10
more years at the U.S. Department of Health and Human Services.
In fact, Mr. Smith headed the Medicaid agency for nearly 7
years, the longest tenure of any Medicaid Director at the
Federal level.
Mr. Smith also worked in both the U.S. Senate and the U.S.
House of Representatives from 1989 to 1998.
Our fourth witness will be Ms. Teresa Miller, the Acting
Secretary of the Commonwealth of Pennsylvania's Department of
Human Services. Previously, Ms. Miller served as the
Pennsylvania Insurance Commissioner from January 2015 through
June 2017. Additionally, she chairs the Senior Issues Task
Force and its Long-Term Care Innovations Subgroup at the
National Association of Insurance Commissioners, or NAIC.
Prior to her work in Pennsylvania, Ms. Miller served as
Acting Director of the State Exchanges Group, the Oversight
Group, and the Insurance Programs Group in the Centers for
Medicare and Medicaid Services at the U.S. Department of Health
and Human Services. She also served as the Administrator of the
Oregon Insurance Division.
Ms. Miller received her J.D. from Willamette University
College of Law and her B.A. from Pacific Lutheran University.
Next we will hear from Ms. Cindy Mann, the former Deputy
Administrator and Director of the Center for Medicaid and CHIP
Services at CMS. Prior to her appointment at CMS, Ms. Mann was
a research professor at the Georgetown University Health Policy
Institute. There she was the founder and director of the Center
for Children and Families.
Ms. Mann also previously worked as a senior adviser at the
Kaiser Commission on Medicaid and the Uninsured. Ms. Mann is
now a partner with Manatt Health.
She received her J.D. from New York University School of
Law and her B.S. from Cornell University.
And last but not least will be Mr. Dick Woodruff, senior
vice president of Federal advocacy for the American Cancer
Society Cancer Action Network. Altogether, Mr. Woodruff has
more than 35 years of experience in Congress, the executive
branch, and the not-for-profit world, including serving as a
Chief of Staff and Legislative Director for members in the U.S.
House of Representatives as well as the Senate.
He also served as the Director of Congressional Affairs at
the National Endowment for the Arts.
Mr. Woodruff is a graduate of Miami University in Oxford,
OH.
I want to thank each and every one of you again for taking
time out of your busy schedules and coming here today. And I
look forward to hearing every one of your remarks.
Senator Cassidy, will you please get us started?
STATEMENT OF HON. BILL CASSIDY, M.D.,
A U.S. SENATOR FROM LOUISIANA
Senator Cassidy. I cannot tell you how honored I am to
testify before my colleagues. I respect you so much. You are
knowledgeable and you are passionate about health care. You are
knowledgeable and passionate about our country.
I hope that you accept that I also have studied health care
and am passionate about it and am passionate about caring for
the uninsured. My work for 30 years in public hospitals in
California and in Louisiana was spent caring for those who have
less.
Let me say first, Senator Wyden, I am so sorry about this
process. I would have preferred hearings, a markup, a
Democratic cosponsor. For 3 years, I have gone around to
Democratic colleagues, several in this room, have met with you
and asked, ``Could we please work together?''
Susan Collins and I came up with legislation which was so
bipartisan, in which a State like Oregon could keep Obamacare
if they wanted. If it is working for you, that is fine. But in
my State, the individual market is collapsing. In Tennessee, it
is collapsing. I could go down the list. Allow us to do
something different.
It was praised by both the left and the right that this was
a bipartisan attempt, sincere. All 10 said they could not help.
Now, after the health-care vote failed in August, I was
assured that now bipartisan cooperation would begin. That has
not happened. In the meantime, the individual market in my
State is collapsing. If you are not getting a subsidy, you
cannot afford your coverage.
There was a friend--I put it on my Facebook page; no one
believes me--and he is paying $39,000 a year for his premium.
People ask us, wait a second, how do you ensure affordability?
Is $39,000 a year affordable? That is not including his
deductible.
So when I asked people, ``Will you help me?'' For 3 years I
have been doing this, and for 3 years I was basically told,
``Nice try.''
I am then presented a choice. Do I say, people will not
help me so I quit trying to help those folks who cannot afford
policies in my State? That is not why I was sent here. I was
sent here to work for them. And if this is the only means by
which I can do so, then I shall.
Now again, before being Senator Cassidy, I was Dr. Cassidy,
caring for the uninsured and Medicaid patients in Louisiana's
public hospital system. My patients had terrible diseases,
multiple chronic conditions, and I did my best to serve my
fellow Americans. I truly believe that Graham-Cassidy-Heller-
Johnson serves these fellow Americans by other means.
The ACA promised affordable health-care coverage, freedom
to keep your doctor, and to keep health-care costs down. In
reality, on the exchange, middle-class families have
skyrocketing premiums, individual mandates that they hate,
$6,000 deductibles with costs inflating and doubling in too-
short a time frame.
Indeed, if there is one thing we can agree on on a
bipartisan basis, Obamacare is failing. Fifteen Democratic
Senators recently declared such while endorsing a single-payer
system. The problems of Obamacare require a path forward.
On a positive note, I was presiding the other day when
Senator Wyden was praising the CHIP program. We agree. Graham-
Cassidy-Heller-Johnson passes a flexible block grant through
the CHIP program, keeping the protections and the requirements
of the CHIP program. We combine the Medicaid expansion dollars,
Obamacare tax credits, the cost-sharing reduction subsidies,
the basic health plan, and distribute them in this means.
By the way, it is a mandatory appropriation. And yes, the
CHIP program requires reauthorization. This will too, but it
does not mean the money goes away automatically in 10 years as
some have absurdly stated.
Let me address the inevitable comment--oh, by the way, we
do not affect one-sixth of the economy; that is a misstatement.
We are not touching Medicare, we are not touching employer-
sponsored insurance, we are not touching Tricare. None of that
is touched. We are in the individual market. We are in the
Medicaid expansion and traditional Medicaid. This is not one-
sixth of the economy.
There will be the inevitable comment that we are ending
Medicaid expansion. Actually, a State could take the dollars
that we are giving and continue the expansion program as they
have it now. They have the flexibility, I can tell you. Despite
me pointing this out, it will be said.
To help States, many of which are not able to meet their
expansion match in 2020, the Medicaid expansion match is
waived. The flexible block grant functions like a combined
1115/1332 waiver.
We preserve protections like mental health parity,
guaranteed issue, prohibiting charging women more, no lifetime
caps.
States applying for waivers must prove that the Americans
with preexisting conditions have access to affordable, adequate
coverage, period, the end. And you define ``affordable'' as
``able to afford.'' Contrast that with $39,000-a-year premiums.
This raises an issue, perhaps to end here. Many on the left
are threatened that we give States and patients the power that
Obamacare usurped. Under this narrative, States are inept,
corrupt Governors scheme to deprive the citizens of their State
of protections, and patients only get better if told what to
do. This amendment rejects that narrative.
And by the way, partisan Virginia gets 4 billion more
dollars; Florida, 15 billion more dollars; Missouri, 5 billion
more dollars, increasing access to cancer screening and cancer
treatment for folks in those States who currently do not have
it. I wonder if those opposing this amendment care about those
in that State, because right now, those in Virginia will have
more for these tests.
We need to pass Graham-Cassidy-Heller-Johnson, returning
power to patients and States, while expanding access to
coverage for millions.
Thank you.
The Chairman. Thank you, Senator.
[The prepared statement of Senator Cassidy appears in the
appendix.]
The Chairman. Senator Santorum?
STATEMENT OF HON. RICK SANTORUM,
A FORMER U.S. SENATOR FROM PENNSYLVANIA
Mr. Santorum. Thank you, Mr. Chairman.
It is an honor to be here before my former committee. And I
am here because I am a father, a father of a child who, like
many outside this room, is in a wheelchair because she cannot
walk and she cannot talk either. So I am trying to speak for
her and for others like her.
I see the hysteria that has been developed around this
bill, and it is really disturbing to me that what is a clearly
responsible proposal that, as many on the right have
criticized, keeps 90 percent of the taxes and 90 percent of the
spending, is going to cause everybody who was ever covered by
Obamacare to be without insurance, that just does not make any
sense. It is irrational. It is not supported by any facts or
any of the evidence.
And it just shows the frustration that many Americans have
outside of Washington in seeing something put together by, let
us just say, not two of the most conservative members of the
Republican caucus, Lindsey Graham and Bill Cassidy, who
sponsored a plan with Susan Collins to try to get bipartisan
support. These are the sponsors of this legislation, people who
are not on the far end of the Republican Party, yet it is being
treated as this draconian slashing.
This is not the first time that I have had experience with
this type of reaction to a change in entitlement programs.
Twenty-one years ago I was in the United States Senate and had
the privilege of managing the bill on the floor of the Senate
to reform welfare. The very same organizations and groups that
are out in the halls and others complaining about this bill
were saying that people would be sleeping on grates and bread
lines would be redeveloped and we would be cruelly cutting
people off all of these services that they so badly needed.
The reality is that we are doing the same thing in this
bill as we did in 1996. That is the idea when I talked to
Lindsey and Bill and others about this idea; it was based on
the success of the 1996 welfare law, a bill that got bipartisan
support.
Even though there was hysteria, there was a recognition
that this program was not doing as well as it could be and that
there were innovations at the State level that could be
replicated and done better, to care for people better, to get
people off of welfare, that we should not measure the success
of welfare as to how many people are on it, but how we
transition them off and get them to work and how we lower
poverty rates.
And the same as here. It should not be how many people we
are getting into a government program, but how much affordable
insurance we are providing for an entire market, like myself,
who is on the Obamacare exchanges and pays around $30,000 a
year for our policy.
Now, I do not know how families do that. I mean, that, to
me, the idea that this is affordable, is ridiculous. It is not
affordable.
And so I came forward, based upon the information that I
had and experience I had in working on welfare, and suggested
that we can do the same.
And I did, by the way, with welfare, when I was on the
committee and even before, I had nine people in my office whom
I hired who were former welfare recipients. I take this
responsibility of getting engaged and involved in public
policy, whether in office or out, that the primary purpose here
is to make sure we have a system that works well for America.
And the hysteria that is being developed here at a bill
that, candidly, is modest in its reductions in spending, modest
in its reductions in taxes, and even modest in the flexibility
that we give to the States outside of the ACA to be able to
provide care for those who are in need in our society who fall
through the cracks----
This legislation is in two parts: one is a block grant of
the ACA monies, as Dr. Cassidy described, and the other is the
Medicaid per-cap cap. As everyone knows, the Medicaid per-cap
cap was proposed by President Clinton. Now it is seen as this
draconian measure. The Medicaid per-cap cap ties the per-capita
rate of growth of Medicaid at around the level of medical
inflation.
Now, we have advocates who have gotten up and said we need
government-run health care for everybody and that is the most
efficient and effective way. Yet when we put the cap on
Medicaid at the rate of inflation for health care, we are told
that this government program will collapse. How can you have it
both ways, that government health care is the most efficient,
but if you put it at the rate of medical inflation, which
includes all these, quote, ``inefficient'' private plans, it is
going to collapse? You cannot make that argument. You cannot
say you are the best, but you cannot keep up with inflation.
On the second, the block grant, it is very simple. We give
States an enormous amount of money. People say, well, this
would be going back to the old system. The old system did not
have $1.2 trillion to be spent by the States to be able to make
the system work.
I look forward to the opportunity of getting into the
details of how we designed this to make sure that States who
expanded Medicaid are not disadvantaged over the long term,
that we gradually ramp in the formula, that we do a lot of
things that Dr. Cassidy and others have worked on to make sure
that this is a fair system, that all poor people in America and
those in the individual market get the opportunity to get some
help from the Federal Government so we can have affordable and
stable insurance markets.
Thank you, Mr. Chairman.
The Chairman. Well, thank you. That was very, very
interesting, as far as I am concerned.
[The prepared statement of Mr. Santorum appears in the
appendix.]
The Chairman. Let us turn to you, Mr. Smith, and take your
testimony at this time.
STATEMENT OF DENNIS G. SMITH, SENIOR ADVISER FOR MEDICAID AND
HEALTH CARE REFORM, ARKANSAS DEPARTMENT OF HUMAN SERVICES,
LITTLE ROCK, AR
Mr. Smith. Thank you very much, Mr. Chairman.
It is a privilege to be with all of you today. And I am
here to discuss the Graham-Cassidy-Heller-Johnson amendment.
And I am also pleased to convey Governor Hutchinson's support
for this proposal, as we believe that it makes a great deal of
sense and will protect the interests of individuals on Medicaid
as well as those who are subsidized in the private sector as
well.
In 2017, CBO estimates that on the Medicaid expansion, the
premium subsidies, the tax credits, the cost sharing, we will
spend about $111 billion, the Federal Government. In 2026,
under the proposal, it will be $190 billion. That is a 70-
percent increase in the amount of Federal spending available to
provide coverage.
In the original estimates, the Congressional Budget Office,
when it modeled the Affordable Care Act for what the coverage
would look like in 2017, in this year--so they modeled it 7
years ago--what they predicted then was very much inaccurate in
that CBO had in its baseline by 2017 that there would be 35
million non-
elderly individuals on the Medicaid program under current-law
baseline. And under the Affordable Care Act, 15 million would
be added to that number. And if you will recall, that is when
Medicaid expansion was mandated under the legislation, which,
of course, turned out not to be true.
Today we have 69 million non-elderly individuals on
Medicaid and CHIP, of which 13 million have been made eligible
by the ACA. So the individuals that CBO predicted would be
receiving subsidies over in the marketplace in fact are in
Medicaid instead.
This legislation puts those two populations together. So
again, now we would form a pool of 22 million lives which are
relatively young and healthy, and that would be the new pool.
Again, everyone keeps talking about, how do we stabilize
the premiums for this population? We keep trying to throw more
money at it. Well, the solution is, put more people into it;
that is what will truly stabilize the pool.
Also, I have my remarks on the CHIP program. Again, I was
privileged to be, 20 years ago, with Chairman Hatch and Senator
Grassley at the time to help create the CHIP program, so I
believe it is a great vehicle to use for that purpose, to build
upon that. And it has the benefits of having a structure
already in place.
CHIP is a very popular program. People know what it is. But
it is also a capped allotment to the States. It is flexibility
to the States. It is deferring to the States on many of the
decisions that have been made. And I would suggest CHIP has
been wildly popular on a bipartisan basis for 20 years.
The third point I want to talk briefly about is per-capita
caps in Medicaid. We already have per-capita caps in Medicaid.
Virtually every State that has an 1115 waiver agrees to a cap
on the amount the Federal Government will give to that State to
live under that waiver, including the State of Arkansas. We are
living under a per-capita cap. If we exceed that cap, then we
are at risk for every dollar above that cap.
States will manage the programs to those caps. Those caps,
by the way--the Office of the Actuary now produces an annual
report on Medicaid spending. And in 2015, the actuaries made
their projections out through the year 2024 for what Medicaid
was going to be spending. Last year, they reduced their
projected spending for Medicaid by $140 billion. Nobody is
arguing that there is somehow $140 billion that has been lost.
You have revised the baseline. The baseline changed. In
many respects, the baseline is changing. It is lowering,
because the States do not have their share of the funds to be
able to continue to accelerate Medicaid spending at the rate it
is.
So, the consumer price index of medical inflation plus one
for the disabled and elderly populations that the proposal
provides for, when you look at the actuaries' report, that is a
higher growth rate than what CBO is estimating that its per
elderly and disabled beneficiary will grow by. So again, the
reality is, slowing spending on a per-beneficiary basis is
lower than what the bill is providing for.
The last point is on work requirements, which are a feature
of the bill, again, we have passed, with Governor Hutchinson's
leadership. Work requirements received overwhelming bipartisan
support in Arkansas. Again, I think that this is a vehicle that
States will be able to readily adapt to, will be ready to put
into place, and will continue the tradition of this committee
in extending coverage to the most vulnerable Americans.
The Chairman. Well, thank you so much.
[The prepared statement of Mr. Smith appears in the
appendix.]
The Chairman. Ms. Miller, we will call on you now.
STATEMENT OF TERESA MILLER, ACTING SECRETARY, DEPARTMENT OF
HUMAN SERVICES, COMMONWEALTH OF PENNSYLVANIA, HARRISBURG, PA
Ms. Miller. Good afternoon, Chairman Hatch, Ranking Member
Wyden, and members of the committee.
I sit here today honored to have this opportunity, but also
very, very concerned about the potential for this legislation
to become law and what that will mean for the millions of
Americans who rely on the Affordable Care Act for quality
affordable health insurance. Since passage of the ACA,
Pennsylvania is experiencing an all-time-low uninsured rate. We
just announced that we have gone from over 10 percent uninsured
before the ACA to 5.6 percent today.
As we face an opioid epidemic that is devastating our
communities, 175,000 people have been able to access substance
abuse treatment thanks to the ACA and Governor Wolf's Medicaid
expansion. I could go on and on about all the benefits people
in Pennsylvania and around the country have realized because of
the ACA, but it is also important to point out that the ACA is
not perfect.
I had the opportunity to testify a few weeks ago before the
Senate HELP committee about ways that we could work together to
stabilize individual markets, which is really the limited area
that needs attention. A group of insurance commissioners from
red and blue States alike talked about targeted reforms that
could be put in place to stabilize our markets to ensure the
ACA works for everyone going forward.
I was optimistic after that hearing because, for the first
time in this debate, it appeared that Senators from both sides
of the aisle were genuinely interested in focusing on the
problem, the need to stabilize the individual market, and
finding a solution to that problem, rather than using the
problems in the individual market as an excuse to repeal the
ACA entirely and, as the National Association of Medicaid
Directors put it, ``make it the largest intergovernmental
transfer of financial responsibility from the Federal
Government to States in our country's history.''
And yet now, I find myself here again talking about a
proposal that would make draconian cuts to Medicaid and force
Governors across the country to make the most gut-wrenching
decisions they can possibly face.
According to an analysis by Avalere Health, Pennsylvania
would lose $15 billion in Federal funding in the next decade.
Kaiser Family Foundation put the number at $22.7 billion. Our
own analysis estimates we would lose $30 billion, assuming
average cost growth. This forces Governors across the country
to make impossible decisions. Who should receive health care: a
child born with a disability, a young adult struggling with an
opioid addiction, a mom fighting breast cancer, a senior who
has worked hard all his life and needs access to quality health
care to age with dignity?
Having been a State insurance regulator in two different
States and having spent time as a Federal regulator, I truly
believe States are in a better position to make decisions
impacting our residents. We know our markets better, we are
more nimble and able to respond to issues impacting our
consumers. So when we hear that you want to give us more
flexibility, you do pique our interest.
I gave the Senate HELP committee some ideas for ways the
Federal Government could streamline the 1332 waiver process and
make it easier for States to get these waivers. But cutting
billions of dollars from Medicaid and giving States reduced
funding in the form of block grants, funding that goes away
after 7 years, is not the kind of flexibility that we are
looking for.
I have been thinking a lot over the past few days about
what we would do in Pennsylvania if this bill becomes law. And
honestly, I am really struggling to figure out how we would
respond. We would have 2 years to completely revamp our health-
care system, work with stakeholders to figure out what a new
system could look like, develop whatever infrastructure would
be needed, make system changes required, pass legislation, get
any necessary Federal waivers, and a host of other activities.
All of this would need to happen apparently without Federal
funding to support these essential planning activities. The ACA
gave States almost 4 years and a lot of funding to support
their work. Oh, and after 7 years, the funding disappears and
the State would be left holding the bag to fund whatever system
we put in place. That alone makes it highly unlikely we would
get anything in place in Pennsylvania by 2020.
In my experience, State legislatures, they do not want to
put a system in place with Federal dollars if we do not have a
way to ensure it is sustainable after we lose those Federal
dollars. But let me be clear. Providing implementation funding
or extending this funding indefinitely into the future would
not fix the insurmountable flaw in this bill: the staggering
cut in Federal funding.
Pennsylvania is facing a $2-billion structural deficit in
our budget now. We do not have a balanced budget for this
current fiscal year 3 months into it, and we certainly do not
have the ability to cover the loss of anywhere from $15 billion
to $30 billion in Federal funding over the next decade.
We have had less than 2 weeks to analyze this bill, a bill
that would have a devastating effect on the more than 3.2
million Pennsylvanians with coverage through Medicaid and on
the Federal exchange. Please do not paper over these draconian
spending cuts, which will inevitably increase the number of
uninsured under the guise of State flexibility.
On behalf of Pennsylvanians, on behalf of children,
seniors, individuals with disabilities, our most vulnerable
populations, I implore you to return to the bipartisan process
that the Senate was engaged in earlier this month and craft a
compromise bill to stabilize the individual market and improve
our current system.
Thank you.
The Chairman. Thank you.
[The prepared statement of Ms. Miller appears in the
appendix.]
The Chairman. Ms. Mann, we will turn to you now.
STATEMENT OF CINDY MANN, FORMER DEPUTY ADMINISTRATOR AND
DIRECTOR OF THE CENTER FOR MEDICAID AND CHIP SERVICES, CENTERS
FOR MEDICARE AND MEDICAID SERVICES, DEPARTMENT OF HEALTH AND
HUMAN SERVICES, WASHINGTON, DC
Ms. Mann. Thank you. Good afternoon, Chairman Hatch,
Senator Wyden, and distinguished members of the committee.
This Nation has made enormous progress, increasing the
number of people who have health insurance and moving health
care to a system that provides greater value with lower total
costs. But we still have a long way to go.
Virtually every major health-care provider and health plan
association and consumer group, from the AMA, the American
Hospital Association and AHIP, to the American Cancer Society
and the American Academy of Pediatricians--those are just some
in the ``A'' category--have voiced opposition to the Graham-
Cassidy proposal. None of these groups, however, would say that
there is not a need for ongoing reforms and improvements in our
health-care system.
Graham-Cassidy, however, would inevitably take us backwards
and in a reckless and dangerous manner. It would create chaos
and uncertainty, new levels of marketplace instability, higher
premiums and out-of-pocket costs for many, and an increased
instability throughout our system. It would also, and probably
most significantly, take away the financial resources and the
certainty about those resources that are critical for States to
maintain coverage and to continue moving forward.
As the group of 10 Governors, both Republicans and
Democrats, wrote earlier this month, Graham-Cassidy is not the
answer. Instead, we need bipartisan efforts to make health care
more available and affordable for all people, including
America's taxpayers.
My remarks look at the key implications of this proposal on
Medicaid and the 73 million people covered by that program,
focusing on three points. First, it is important to keep in
mind that the
Graham-Cassidy proposal builds on the Better Care and
Reconciliation Act, BCRA, the bill that was voted down by the
Senate in July.
BCRA imposed deep cuts to the Medicaid program, and so does
Graham-Cassidy. CBO estimated that BCRA would have cut Medicaid
by $756 billion over 10 years, and those cuts grow over time
because the per-capita cap included in both proposals gets
tighter in the out-years.
The cuts in BCRA to Medicaid come principally from changes
to the Medicaid expansion funding and from the caps on the
Federal funding for the program. Graham-Cassidy maintains and
deepens the cuts to Medicaid expansion that were in the BCRA
bill. Not only would States no longer get the enhanced funding
that is provided under the ACA, but under the Graham-Cassidy
proposal States would not even get funding at regular match
rates to be able to cover very low-income adults.
And Graham-Cassidy, like BCRA, would impose arbitrary caps
on Federal funding for virtually every population covered under
traditional Medicaid. That means the Federal Government would
end its commitment to share the full cost of providing coverage
for pregnant women, for children--Medicaid covers one out of
three children in this country--and for people with
disabilities and for the elderly.
Six out of 10 dollars spent in the Medicaid program are for
people over 65 and people with disabilities. If Congress adopts
the Graham-Cassidy proposal, it is cutting and capping funding
for the very beneficiaries whom the supporters of this
legislation point to as those whom Medicaid ought to protect.
My second focus is on the block grant that Graham-Cassidy
creates in place of the Medicaid expansion dollars and the tax-
cut subsidies and cost-sharing reductions.
Let us start with basics. First, it is a block grant, which
means the dollars do not grow based on actual cost of care or
based on enrollment. Overall, at least looking at the version
of the bill that was released on September 13th, the block
grant cuts about $82 billion between 2020 and 2026. But if
health-care costs are higher than projected--the need for
coverage or subsidies is greater than anticipated--the gap
between actual need and funding widens.
The second basic fact is that the funding for this block
grant, as has been pointed out, is time-limited. But let us go
beyond the basics. Graham-Cassidy reshuffles the deck,
allocating dollars not based on historic spending or projected
need or costs, but to the point where everybody gets, every
State gets, the same level of funding per poor person. You
could say it creates a one-size-fits-all funding formula. The
problem is, one-size-fits-all makes little sense.
Our analysis in a report attached to my testimony is
similar, directionally, to other analyses. Twenty-nine States
would receive less Federal funding than they would under
current law with an average reduction of 19 percent.
In 2026, 18 States plus the District of Columbia would lose
one-quarter or more of their funding, including six States
represented on this committee: Delaware, Colorado, Michigan,
New Jersey, Oregon, and Washington. Six States, including
Alaska and Oregon, would see their funding cut by half or more.
There would be adjustments, but in some cases, whether
those adjustments are made and, in all cases, how those
adjustments would be made would be left to the Secretary's
discretion. States do not know and will not know what those
allocations will be, but notably those adjustments have to be
budget-neutral. Upward adjustment for one State means a
downward adjustment for another State.
The block grant does provide States with broad flexibility,
except, of course, with respect to whether a State can continue
to rely on Planned Parenthood clinics to provide women health-
care services.
But how many of us really believe that a State that loses
one-fourth to one-half of their funding will be able to replace
the lost coverage and to improve stability and costs in the
marketplace? That kind of flexibility only means that States
will be able to decide which groups of people will not get
coverage, which services will not be covered, and how many
people will see their premiums and out-of-pocket costs go up
rather than down.
Finally, I just want to touch briefly on the issue of
implementation. Simply stated, Graham-Cassidy would create
chaos in our health-care system with frightening implications.
Twenty-three million people are projected to receive
coverage through the marketplace and the Medicaid expansion in
2019. On January 1, 2020, by the terms of this proposal, that
coverage and those subsidies will end. It is simply impossible
for States to make their plans and have new programs in place
by then, even without considering that they will not know how
much money that they have from year to year or whether they
will have any money in 2027.
On this point, let me quote Dr. Atul Gawande, who wrote
that with respect to implementation, ``It is not just
impossible; it is delusional.''
There are no winners in this bill, but there are many who
will lose, and many others who will be at grave risk. It is
instructive to consider the array of special fixes in this
bill. There are many, and they are growing with every version,
all aimed at softening the blow for one State or another.
Whatever else you might think about these special deals for
certain States, they do help us appreciate just how flawed the
underlying structure of this bill really is.
Thank you for your time.
[The prepared statement of Ms. Mann appears in the
appendix.]
The Chairman. Mr. Woodruff, we will take your testimony.
STATEMENT OF DICK WOODRUFF, SENIOR VICE PRESIDENT OF FEDERAL
ADVOCACY, AMERICAN CANCER SOCIETY CANCER ACTION NETWORK,
WASHINGTON, DC
Mr. Woodruff. Thank you, Chairman Hatch, Senator Wyden, and
members of the Finance Committee. I appreciate the opportunity
to speak about the needs of cancer patients today and other
patients with serious and chronic illness.
But first, I want to say, as you have said, this committee
has a long tradition of bipartisan achievement and workman-like
effort. And passing the CHIP bill many years ago, funding it
with the tobacco tax--that was a two-fer for cancer.
And I am honored to be here before you today.
Let me start with a short personal story. I am sure
everyone in this room has one, given that one in two men and
one in three women are diagnosed with cancer in their lifetime.
My mother was diagnosed at the age of 48 with breast cancer. In
1963, the standard treatment was a radical mastectomy and
massive radiation. She survived and lived to be 93, which was a
wonderful thing, but she was lucky.
For 45 years thereafter, she lived with a preexisting
condition. My dad had a good job with insurance that kept her
covered until she reached Medicare eligibility, so she was
lucky again.
My point is, until 2010 cancer patients and survivors had
to be lucky to get coverage and access to care. Those who had
to buy in the individual market were mostly priced out of it.
Others faced annual and lifetime limits on their benefits. And
as a consequence, many families with cancer faced medical
bankruptcy.
That all changed with passage of the Affordable Care Act.
Patients had certainty and stability. They could buy insurance
that covered their care no matter their health status. Very
low-income, working, single men and women for the first time
had access to coverage through the Medicaid expansion.
Yes, the current system has flaws. Premiums are far too
high for some families. And 19 States declined to expand
Medicaid, which has left over 4 million low-income citizens
uncovered. That Medicaid patchwork created by the 2012 Supreme
Court decision is revealing of what could happen if the Graham-
Cassidy bill is passed, creating a new patchwork of standards
in 50 States in both Medicaid and the individual market.
The bill before you would completely restructure the
individual markets and Medicaid, as others have said around the
table here. And how that would come out in each State is not
known.
What is known is that the proposed cuts to Medicaid
delivered through the block grants and per-capita caps will end
Medicaid coverage for millions of working men and women and
children and disabled citizens.
The mandatory patient protections in current law that
explicitly prohibit pricing based on health status, the
essential health benefits, and the ban on lifetime and annual
caps that are tied to those benefits, all of those would become
discretionary depending on what State you live in, and now some
States could decide not to cover even preventive services, like
cancer screenings, routine mammography, or colonoscopy.
Prevention is the key really to treating cancer, and it is
really a way to have health care much less expensively if we
encourage prevention.
A couple of weeks ago I was struck by the common-sense
statement that was made by former Governor and HHS Secretary
Mike Leavitt during his testimony before the HELP committee.
When he was asked about the appropriate balance between Federal
and State involvement in health care, he said we need to have
national standards and State solutions, because without a
national standard that ensures adequate and affordable
coverage, how do we really make sure that people get the
treatment they need when they get sick?
As others have said, the timeline written into Graham-
Cassidy for each State to restructure Medicaid and redevelop
their individual markets by 2020 is not realistic and not
likely feasible. In the words of the State Medicaid directors,
States will need to develop overall strategies, invest in
infrastructure and systems changes, negotiate provider and
managed-care contracting, et cetera, et cetera, et cetera. This
group, it is said, is not a group with a reputation for
hyperbole.
We are worried at the Cancer Society for millions of people
who may lose their insurance. Hundreds of billions of dollars
will be taken out of health care if this bill passes.
If the EHBs go away, so does the protection against annual
and lifetime caps, because the caps are tied to those benefits.
Insurers could be allowed to offer plans that do not cover
treatment for all of the services that cancer patients need. In
that situation, the plan they need may not even be offered or
it may be too expensive for them to afford, and then they would
go without coverage. And this is what happens: their cancers
are discovered later, they are more expensive to treat, they
have a lower chance of survival, their medical costs force them
into debt, they forgo preventive care and cancer screenings,
and we are right back to where we were 7 years ago.
With health care, what people want is stability and
certainty. Our goal is to relieve patients of their fear.
Cancer is scary enough, but what is really frightening is not
being able to afford to fight it.
The American Cancer Society Cancer Action Network and our
affiliate, the American Cancer Society, are nonpartisan
organizations, and we believe the only way to resolve this long
impasse over health care coverage is a bipartisan solution.
We would like to work with the Finance Committee going
forward and help you find solutions that improve the current
health-care law, ones that make premiums affordable for all
Americans who need health care.
Thank you again for the opportunity.
The Chairman. Well, thank you, sir.
[The prepared statement of Mr. Woodruff appears in the
appendix.]
The Chairman. We are grateful for this panel. It has been
an excellent panel.
And let me just start the questioning by asking you,
Senator Cassidy, can you please walk us through the changes
made to the text that posted on your website this morning so we
all have a clear understanding of the current language?
Senator Cassidy. Yes. So what we found as we introduced our
first bill is that the rate of inflation was far higher for the
individual market and Medicaid markets than we had anticipated.
And that rate of inflation did cause a transfer of dollars from
those States which had expanded to those which had not. We want
equity so that, no matter where an American lives, she or he
can get the care they need, but we also did not want to see an
abrupt change.
So we did a couple of things to, frankly at the expense of
the non-expansion States, prolong the glidepath to equity, so
now equity only occurs out in 10 years, not in 6.
Secondly, we capped the amount of money a State could see
as an increase to 25 percent. So Mississippi, for example--that
ends up going up dramatically because they are so low now--is
capped at 25 percent per year. They do really well. The folks
in Mississippi will have far more resources to screen and treat
for cancer than they do now; but nonetheless, it prevents a
dramatic shift for other States.
And so in that way, secondly, we went around and we looked
at some States--they were just outliers for whatever reason.
Hawaii and Alaska have Federal poverty levels that are 1\1/2\
times that of the other 48, but they only get paid by Medicaid
as if they were the same as the other 48. So we actually, for
those two States, we corrected the amount they get from
Medicaid so that Hawaiians and Alaskans will have a more
appropriate reimbursement for the costs in their State.
We did other things like that, trying to minimize, whether
it was a blue State or a red State, a problem they may have
with this new formula.
The Chairman. Let me ask you this, Mr. Smith. How can the
Federal Government work with States to promote private-market
coverage for low-income individuals while preserving Medicaid
for the most vulnerable?
Mr. Smith. I think, Mr. Chairman, States are already
experimenting with those strategies now, including Arkansas, in
which Arkansas elected to have the Medicaid expansion under the
previous administration. We have continued to refine that and
develop it. But the reality is, the public/private partnerships
that we have been finding in Medicaid for the last 20 years,
private-sector managed care companies, are now delivering a
great deal of the services to the Medicaid population.
In Arkansas, for the private, qualified health plans
marketed on the exchange, 80 percent of the amount of subsidies
is for a
Medicaid-eligible population.
So again, I think that where we are in these private/public
partnerships--they have been underway for 20 years--there is a
platform to build upon.
The Chairman. Thank you.
Senator Wyden?
Senator Wyden. Thank you very much, Mr. Chairman.
Mr. Chairman, first of all, when this hearing was
announced, we set up on our side a website so we could hear
from the American people. Almost 27,000 citizens commented.
I would ask, per our agreement, unanimous consent that all
emails sent to our site by the start of this hearing be entered
into the record.
The Chairman. Without objection.
[The email responses can be viewed on the committee's
website.]
Senator Wyden. Thank you, Mr. Chairman.
First of all, before I get into my questions, I want to
make two points that I think my colleagues are going to echo.
First of all, we feel very strongly on our side we ought to be
working on a bipartisan basis today.
The Chairman. I agree.
Senator Wyden. There are two clear opportunities for the
Senate to do that. The first is our bipartisan CHIP bill, where
funding is going to run out at the end of the week. And the
second is working to stabilize the private insurance markets.
That is what we are for on this side of the aisle.
And finally, we think this process has just been an
abomination. We are talking about something that is going to
affect millions of Americans. We do not have any objective
information about what it is going to mean to people's
premiums. We do not know what it is going to mean with respect
to coverage. We do not know whether the health markets are
going to survive in the next year. We ought to have that
information. That is what you get if you take the time in the
regular order.
Now, Senator Cassidy, let me start with you. You managed to
bring together people and organizations in the health-care
field who rarely agree. I guess congratulations are in order,
because they all think what you are talking about is a
disaster. And they particularly agree that America's health-
care system is going back into the business of charging folks
with preexisting conditions more for health insurance.
Now, I would like a ``yes'' or ``no'' answer to this
question. The question is, do you continue to believe that the
thousands of doctors and hospitals and patients' groups who are
writing us saying that you are wrong on preexisting conditions,
do you continue to believe as of today they are wrong? And that
is a ``yes'' or ``no'' answer.
Senator Cassidy. That is begging the answer. I think if you
are in an orange State in which you did not expand Medicaid,
so, therefore, the patients and hospitals in your State do not
get benefits, if you are in Maine or Missouri or Florida or
Virginia, you are pleased about this bill.
Senator Wyden. Colleague, I asked you for a ``yes'' or
``no'' answer.
Senator Cassidy. And so the simple answer--but you are
begging the answer, and I think it is more important to have
the right answer than the one that is begged. And I do not mean
to be disrespectful.
The Chairman. Yes, he should----
Senator Cassidy. But the Tennessee Governor said this is a
gold mine or a Godsend or something like that for Tennessee. If
you are a doctor or hospital in Tennessee or Missouri or Maine,
you are so pleased about it.
Now, if it is a national association----
Senator Wyden. Mr. Chairman, let the record show that our
colleague does not want to answer the question. And it appears
to me that the revised bill, the one we got this morning,
indicates that a State could allow insurers to set higher
premiums based on a person's health status.
Senator Cassidy. That is not true, by the way.
Senator Wyden. Now, what I would like to do----
The Chairman. Well, let me----
Senator Wyden. You are entitled to your opinion, you are
not entitled----
The Chairman. Senator, let me just interrupt for a minute,
and I will give you the extra time.
Look, I want our colleagues treated with great respect. It
is not easy for him to testify on this, although it is because
he is a doctor and he understands this probably better than
anybody in this room, or at least any of us, although I was a
medical liability defense lawyer, so I am not some neophyte
here. And I have probably passed more health-care bills than
anybody, certainly in the Senate.
So let us show some respect for Senator Cassidy. This is
not easy for him. The fact that you disagree with him, that is
fine. But he ought to be able to disagree with you also. But go
ahead, we will give you back your time.
Senator Wyden. Mr. Chairman, one of our past great
chairmen, Pat Moynihan, said everybody is entitled to his own
opinion, but not his own facts. So let us hear from the
American Cancer Society with respect to the real facts. They
have a lot of members who understand the hurt that comes from
being discriminated against for having a preexisting condition.
Mr. Woodruff, what do you think with respect to this bill
and what it is going to do to people with a cancer fight on
their hands?
Mr. Woodruff. Well, it does not protect them, Senator. It
basically makes the patient protections that were enacted into
law in the Affordable Care Act discretionary on the part of
each State. And each State can decide to keep those patient
protections or not.
But what is important about what the act achieved is, it
created a definition, a national standard for what is adequate
insurance and what is affordable.
And so with the essential health benefits, we actually have
an assurance that when you buy insurance, it is going to cover
the services that you need when you are sick, whether you have
cancer or any other disease. The essential health benefits are
there to protect you.
Senator Wyden. Thank you.
Mr. Woodruff. Sure.
Senator Wyden. And I want the American people to understand
the consequence of that statement. The Cancer Society knows
something about what it means for patients to get clobbered by
an extraordinary illness, and what they have said is, this
opens up the door to charging those people more.
Now, let me ask one other question if I might, Senator
Cassidy. We are trying to make sense out of all the bills that
have been released. So here is the first bill. This was posted
on your website on September 13th. This is the second bill that
was on Senator Graham's website. That was on September 13th. We
got a third version last night at 7:30, and we got a fourth
version last night at 7:50, and then we got a fifth version at
9:23 in the morning.
Now, is this bill the one that the United States Senate is
going to actually be voting on? Because I think the American
people would like to know. We are on the cusp, we are on the
eve of voting on this extraordinary piece of legislation. We
are trying to sort out what it is people are even going to vote
on, let alone the fact we do not know what is going to happen
to their premiums, we do not know what is going to happen to
their coverage, we do not know what is going to happen to the
individual markets. Is this what we will actually be voting on?
Senator Cassidy. A couple of things, Senator Wyden, I----
Senator Wyden. That is a ``yes'' or ``no'' answer,
colleague.
Senator Cassidy. Can I say something, please?
Senator Wyden. Of course.
Senator Cassidy. I apologize earlier if I was rude to you.
And I am sorry; I did not intend to be. The last version was
correcting drafting errors; 99.9 percent the same, it just
corrected drafting errors.
And lastly, I will say it is 148 pages, not 990 pages as
was the Affordable Care Act. So the American people should be
able to read this and comprehend it.
Senator Wyden. So is this the last version?
Senator Cassidy. Yes, I believe so. I mean, there might be
a drafting error. I hope correction of a drafting error does
not constitute a whole other version; it is just, like, a
drafting error.
Senator Wyden. All right. Again, I want to highlight,
colleagues, we have one of our colleagues--and I want to treat
every member of the Senate with the opportunity to be heard,
but we got this at 9:20. I just do not think when you are
talking about a bill of this magnitude and our colleague saying
he believes that this is the final version, that that is good
enough when we are talking about putting at risk millions of
Americans.
Thank you, Mr. Chairman.
The Chairman. Thank you, Senator.
Senator Grassley?
Senator Grassley. First of all, for the people who
introduced this bill, I want to thank you for your leadership,
truly improving the American health-care system.
The point has been made--I think Senator Wyden made a point
about all the stakeholders who are involved in this bill and
against it. They have concerns about it. I think that those of
us in Washington know that when all those strong forces speak
up, it is to protect the status quo or protect their interests;
it really is not about providing adequate health care for
Americans.
What I care about is what happens to Iowans. Obamacare has
failed in Iowa. There is only one company planning to offer
insurance in 2018 in Iowa. That company's premiums are well
over a 50-percent increase. People in Iowa tell me their copays
and deductibles on Obamacare make it too expensive to use.
These are issues that must be addressed.
Today, despite our ideological differences, we are able to
have a discussion about a path forward.
Dr. Cassidy, if I could have your attention, does this bill
provide more dollars in 2026 in Iowa than it receives today in
Medicaid subsidies and reinsurance?
Senator Cassidy. It does.
Senator Grassley. Well, obviously, it is not a cut then. Is
this not slowing the rate of growth?
Senator Cassidy. It does slow the rate of growth across the
country. It does.
Senator Grassley. Doesn't everyone agree we need to slow
the rate of growth in health-care spending?
Senator Cassidy. Apparently not everyone, but I would.
Senator Grassley. Okay.
Senator Cassidy. And by the way, I also say that I have
words from Senator Wyden, when he previously introduced a
Medicare bill, in which he said a cap on growth serves as a
backstop, and the best way to hold down health-care costs is to
give Americans the ability to hire and fire their insurance
company.
So I think that these caps on growth have been something in
the past which have had bipartisan support.
Senator Grassley. To you also, do States have the right
incentives under the current Medicaid program matching-funds
system to control costs by coordinating care and fighting
fraud?
Senator Cassidy. You can empirically say they do not, that
it is a cost-plus program: the more the State spends, the more
they get. The only limit is on the ability of the State fisc to
support their end of the match.
Senator Grassley. Lobbyists for the American Hospital
Association, the American Medical Association, the AARP, and
the insurance companies all endorsed Obamacare. Could you say
that these folks have a financial interest that does not take
into account individuals in Iowa?
Senator Cassidy. If you look at the stock prices of
insurance companies, pharmaceutical companies, and for-profit
hospitals since Obamacare passed, they have done extremely
well. In parallel, premiums have risen for those who do not get
subsidies, and tax outlays have risen for the American citizen.
There is a direct relationship between the two. They have done
extremely well under the Affordable Care Act.
Senator Grassley. Okay. I have time left for three
questions, so I hope I can have short answers.
I want to ask, Mr. Smith, is Medicaid sustainable at its
current inflation rate?
Mr. Smith. Whether you look at the Government
Accountability Office or the National Association of State
Budget Officers, the answer would be ``no.''
Senator Grassley. Ms. Mann, is Medicaid sustainable at its
current inflation rates?
Ms. Mann. States are working very hard right now and have
been to be able to improve their programs through better
delivery of care and different payment mechanisms that reward
value rather than volume. Taking away the foundation of
coverage will only make costs grow because people only come in
when care is needed and more expensive.
So we need to control the rate of growth, Senator, but we
need to do that in a way that improves care rather than takes
care away.
Senator Grassley. The same question to you, Ms. Miller. Is
Medicaid sustainable at its current inflation rates?
Ms. Miller. Thank you, Senator. I would echo Ms. Mann's
comments and also say I think this whole debate for the last
several years has been about coverage, and we have not been
talking about the cost of health care. At the end of the day,
insurance is a reflection of the cost of health care. So if we
do not have a debate in this country and a discussion about how
we get at the underlying costs of care, we have a major
problem. That is really the debate we should be having and the
discussion we should be having.
Senator Grassley. Okay.
The Chairman. Senator Stabenow?
Senator Stabenow. Well, thank you very much, Mr. Chairman.
I have so much to talk about, I am not sure where to begin.
And I did want to talk about specific provisions.
And thank all of you for being here.
But I do feel like I need to talk numbers, even though this
has got to be about people, not numbers. Let me just say, the
truth of the matter is, when we cut down the number of people
walking into emergency rooms who do not have insurance, which
is what has happened in Michigan, 50 percent fewer people
walking into the emergency room who cannot pay, the State of
Michigan is saving money.
Our Republican Governor working with Democrats and
Republicans in the legislature did the right thing, made sure
that people who are minimum-wage workers could receive health
care and take their children to the doctor. And what has
happened? We have saved $435 million in taxpayer money because
people can go to the doctor instead of using the most expensive
way to get health care, which is the emergency room.
Let me also just say that it just came across the news that
Standard and Poor's has now said that this bill would cost
580,000 jobs in 2027--580,000 jobs--so that is something we
certainly want to look into.
I think I want to take just a moment to go to this whole
question of whether or not this, as Senator Santorum said, is a
modest change--and welcome back to the committee--a modest
change or, as Ms. Miller said, a staggering cut, because that
is a pretty big difference.
And Senator Cassidy has indicated that, well, it is a block
grant, Graham-Cassidy is a block grant, and after 10 years we
can just continue it like we do other block grants.
Well, here is the reality. In 10 years, to continue that
block grant would cost $190 billion for that next year at level
funding. The entire Health and Human Services budget for our
country is $164 billion. So if we stopped doing everything else
in education and health and human services, you could not pay
for extending that block grant. It is not believable. It is
just not credible.
And I want to show one other thing. These are the
staggering numbers for me in Michigan, because the cuts to
Michigan when this is fully implemented, according to Avalere,
are $140 billion--$140 billion. Our Governor just signed next
year's budget, $56 billion. There is no way--there is no way--
that we will not see people's health care, nursing home care,
children's health care, cut as a result of this bill.
Let me get into specifics. And let me talk about something
near and dear to my heart, and that is, under essential
benefits we have said that maternity care would be covered. And
as a result of that--and I do have to say that maternity care
was a major debate in this committee as one of the 10 essential
health benefits, trying to make sure that just being a woman
would not be viewed as a preexisting condition or somehow women
have to pay more for a rider if a young family wants to have a
child.
Interestingly, my staff tells me it was 8 years ago today
in this committee when a former colleague from Arizona and I
had a debate back and forth about whether or not we should
cover maternity care. He said he did not need it, and it should
not be covered. I reminded him that his mom probably did. And
so we ended up putting it in.
And so now here we are. We have a situation where we could
very easily be going back to pre-health-reform days when in
Michigan only 4 percent of the plans that a young couple could
get on the individual market would cover maternity care.
And we know from studies that young couples get married and
may not be planning on having a child for a long time and then,
oops, more than half the time there is an unplanned pregnancy.
And so then she has a preexisting condition, and prior to the
Affordable Care Act could not find any care.
We also know that to get an average coverage rider at that
time was over $17,000. If you could not find coverage, you
would be paying from $30,000 up to $50,000 out of pocket.
And so, Ms. Miller, I wonder if you might respond to the
issue of maternity care and your experience as an insurance
commissioner. Can you talk about what the individual market
looked like for women a few years ago before maternity coverage
was a basic benefit?
Ms. Miller. Thank you, Senator. And I think my experience
is similar to what you just indicated. I think women before the
ACA, if they had coverage in the individual market, often did
not have an option to purchase coverage that included maternity
as a benefit.
We have a lot of discussions about what should be in the
essential health benefits package, and this bill obviously
gives States a lot of latitude to waive those essential health
benefits. But where I struggle is, when you start looking at
those essential health benefits, I do not know which one is not
truly essential. And maternity coverage is certainly one of
those benefits that, in my mind, is absolutely essential.
And I worry that if we go back to the world that we had
before the ACA, where women in the individual market could not
get coverage to cover maternity care, then they are left paying
out-of-
pocket tens of thousands of dollars if they have a baby. And I
think then we return to a world where we see people going
bankrupt because they simply cannot pay for the medical bills
that they have.
Senator Stabenow. Thank you very much.
Thank you, Mr. Chairman.
Senator Roberts [presiding]. The acting presiding chairman
recognizes Senator Roberts.
Thank you, Mr. Chairman. [Laughter.]
Fact: The Affordable Care Act----
Senator Bennet. I object. Just kidding. That was a joke.
[Laughter.]
Thank you, Mr. Chairman.
Senator Roberts. Would the timer please not count the
gentleman from Colorado's untimely insertion of his remarks?
This is about much more than trying to fulfill campaign
promises, I think. Simply put, the Affordable Care Act is not
affordable. It is failing the people, the very people it
promised to help. Insurers continue to pull out of markets,
then for their coverage in States, they are requesting dramatic
premium increases again for next year.
In Kansas, premiums have doubled since the law has been in
effect. Next year, if we assume all the plans have filed rates
and the States sign the final contract in the next few days,
all Kansans will have just two options of insurance carriers on
the exchange, and one is on a teeter-totter. They may also face
premium increases of up to 29 percent.
When I was back home at the State fair in Hutchinson, KS
just a couple of weeks ago, there was nothing but concern and
frustration and, yes, anger from my constituents over the law's
failures and questions, if not demands, as to why we here in
the Senate have not successfully passed reform.
Now, I do believe, as has been pointed out, that we reached
bipartisan agreement that the law is not working. Over in the
HELP Committee, as has been pointed out, we have held numerous
hearings over the past several weeks to review proposals to
address premiums and stability in the individual market next
year. Unfortunately, many of our colleagues simply wanted more
money to patch this problem, not proposals to address many of
the law's fatal flaws.
There is another alternative out there. A longtime champion
of single-payer, Senator Bernie Sanders, has recommended
Medicare for all, government-run health care and has
reintroduced his proposal with 16 Senators of my friends across
the aisle endorsing that idea.
I am continuing to review the proposal before us from
Senators Graham and Cassidy and others, getting feedback from
actuaries at the Congressional Budget Office and, most
importantly, Kansans. What I am positive of is that this
proposal that we have before us certainly is better than
socialized medicine.
Senator Cassidy, one provision that is included in your
proposal, and many of the other proposals Congress has
considered over the last year to address the increasing growth
in the Medicaid program--I am being repetitive, but I think it
needs to be repeated--is switching from an open-ended
entitlement to what is known as per-capita caps.
Would you characterize such a reform proposal where
spending continues to increase every year, every year, as
slashing the program?
Senator Cassidy. No.
Senator Roberts. While its inclusion in the debate
surrounding the Affordable Care Act has led many to believe
this is a Republican-only idea, it is not. It was actually
something proposed by former President Clinton, embraced by
former Chairman Baucus of this committee, then-Senator Biden
and Senator Patty Murray.
Our Kansas Medicaid folks tell me they estimate Medicaid
spending in our State will increase 3 percent a year over the
next few years.
Senator Cassidy, what is the growth rate in your proposal
for my State?
Senator Cassidy. There are two aspects to your State. In
the traditional block grant, if you will, Kansans will have
lots of money for cancer screening, et cetera. In Kansas under
our proposal you will go from receiving $2.9 billion from 2020
to 2026 under current law to $4.7 billion from 2020 to 2026 to
provide cancer screening and cancer treatment for lower-income
Kansans.
Senator Roberts. Is it fair to say the Kansas cap is in
fact higher than what they currently spend?
Senator Cassidy. Yes. You can also supplement, if you will,
the traditional Medicaid budget with the extra dollars that
Kansas is receiving. And you have the flexibility to do that as
well.
Senator Roberts. Let us go to the ``yes'' or ``no''
questions, but you can cheat on that a little bit. Are
dependents up to 26 still allowed to remain on their parent's
plans?
Senator Cassidy. Yes.
Senator Roberts. Will mental health parity requirements
still be in place?
Senator Cassidy. Correct.
Senator Roberts. Let us say a State does submit a waiver to
redefine the essential health benefits. That has been a
concern.
To Ms. Miller and to Ms. Mann, would prior State-mandated
benefits still be in effect, or are we looking at a Wild West
like some are claiming?
Senator Cassidy. No--one, there is the supposition that
Governors are not going to take care of the people in their
State, which kind of underlies all these questions by some who
have opposed the bill. I disagree; I think Governors want to
take care of the folks in their State.
But if they apply for a waiver, the statute specifically
says that the Governor must establish that those with
preexisting conditions have access to, quote, ``adequate and
affordable coverage.'' If they fail that, there is a provision
in which the Secretary of HHS can pull dollars back, both deny
and pull dollars back, if they misuse the funds by not
providing access to adequate and affordable coverage.
Senator Roberts. Senator Carper?
Senator Carper. Thanks very much.
Welcome to all of our witnesses. Thank you so much for your
great testimony, your presence today.
I have a friend. You ask him how he is doing, he likes to
say, compared to what? And I would like for us to go back
about, oh, gosh, 8 years or so ago, to the time we spent in
this room debating the Affordable Care Act. We did not have 1
day of hearings. We had, as I recall, 97 hearings, roundtables,
and walk-throughs on health care reform--97.
The Senate Finance Committee itself did 8 days of markup on
the legislation. I think 130 amendments were considered. We
actually had the folks who run CBO here at this table to tell
us what the effect would be on our budget if the Affordable
Care Act were adopted. And we were told that under their score,
which they actually had time to produce, the budget deficit
would be reduced in the first 10 years by $130 billion and the
second 10 years by $1 trillion.
During the course of the debate here in this committee and
the Health, Education, Labor, and Pensions Committee, some 300
amendments were offered, 160 Republican amendments adopted.
The Senate then spent 25 consecutive days in session on
health-care reform, the second-longest in the history of our
country.
We are here for 1 day of a hearing--1 day.
You ask my friend how he is doing, he says, compared to
what? Well, how about compared to what you participated in, Ms.
Miller, in the last several weeks before the Health, Education,
Labor, and Pensions Committee? They did not just have one
hearing. Senator Alexander and Senator Murray had 4 days of
hearings. Governors, insurance commissioners, providers, health
insurance companies, health economists from all over the
country--4 days. And those were preceded each day by
roundtables, bipartisan roundtables where people like us who do
not serve on the HELP Committee could actually meet with and
question the witnesses, including you. That is what we did.
This is an unprecedented effort. One of the things that I
take my hat off to--and I think our two Republican colleagues,
one currently here and one who used to be here, with whom I
worked on welfare reform, a bipartisan effort, look for a panel
of witnesses to be able to unite us. And I would say this
proposal from my friends has united some 400 organizations,
health-care organizations and groups--I have never seen a
coalition like this in my life.
Maybe they are all wrong. Maybe they are all wrong. They
stretch from coast to coast, every nook and cranny. But they
say, please do not do this, slow down, hit the pause button,
and do what Ms. Miller has suggested over and over again and
which our colleague John McCain suggested again as recently as
last week.
One of the things that is missing here is--Obamacare, where
did it come from? It came really, initially, from the Heritage
Foundation. They were asked to develop a market-based
alternative to Hillarycare, and they did. It was introduced in
the United States Senate as legislation by John Chafee,
Republican from Rhode Island, cosponsored by two of our
colleagues here. The senior two Republicans on this committee,
Orrin Hatch, Chuck Grassley, cosponsored that legislation.
It is called Obamacare. Barack Obama had nothing to do with
its creation. This is a Republican invention. And frankly, as
one Democrat, I thought it was a pretty good invention. It is
kind of like Dr. Frankenstein operating on his patient and
trying to kill it. Well, why do we not fix it?
And let me say, Ms. Miller, during the debate and the
hearings that you have participated in, what were some of the
good ideas to fix that which the Republicans initially created
and now call Obamacare? What are some of the cures?
Ms. Miller. Thank you, Senator. I think what we heard from
Commissioners from red States and blue States is, you know, the
problems with Obamacare are really just in the individual
market. And most of the people in that market have access to
financial assistance, so the law is actually working well for
them. It is really for the people who are not getting financial
assistance that it is not working well.
But I think what you heard from all of us, whether we are
from a red or blue State, is that continuing to pay cost-
sharing reductions, CSRs, implementing a reinsurance program,
ensuring that we have an effective mandate in place, making
sure we get more young, healthy people into the pool, and then,
importantly for our whole system, trying to figure out how we
can get at the underlying costs of care and try to reduce
those, those are things I think we could all get behind.
And there is a path to a bipartisan solution here to fix
the individual market, which is really where the problems are.
If we all came together, I know we could get there. And I think
we outlined that in the HELP Committee.
Senator Carper. Yes. Colleagues, I was in Boston. I was in
Boston last Friday, and I talked to a number of people there
about Romneycare, which is really based on the Heritage ideas.
And I said, how are you guys doing with the Romneycare up here?
They said, 98 percent of our people are covered. The increase
in our premiums for the last year was 4 percent. And one of the
reasons why is because they have a healthy mix of people to be
insured and they have a lot of competition within the
exchanges.
That is what we need to do, and we have to fix this. The
idea of simply doing this, the legislation that is before us
today, and not stabilizing the exchanges, which are eminently
stabilizable, eminently so, is a big mistake.
Thank you.
Senator Roberts. Thank you.
The distinguished Senator from Ohio, Senator Portman.
Senator Portman. Thank you, Mr. Chairman.
And to my colleague, Mr. Carper, nobody is more focused on
a bipartisan solution than you. I get that.
I will say that the experiment in Massachusetts was what
they wanted to do. And with a lot of flexibility they were able
to put together a plan that works for them. Their costs are
also very, very high, their health-care costs are probably some
of the highest in the country. But that is how they chose to do
it.
And I think what has been missing a little bit in this
debate is, you know, what this is all about. And it is a very
different proposal than the proposals that we have been looking
at previously.
This is one reason that Senator Graham and Senator Cassidy
have received some heat from conservatives, because it takes
the funding in the Affordable Care Act and it sends it back to
the States and gives the States the flexibility to be able to
do what they think is right for their citizens and to be able
to more effectively cover low-income citizens in those States.
I totally agree with what Ms. Miller and Ms. Mann,
Democratic witnesses, this morning have said in terms of
getting at the underlying costs of health care. I would just
suggest that one way you are going to get at the underlying
costs of health care is to give the States that flexibility to
be able to get at it. And we seem to be sort of talking past
each other a little bit, but that is fundamentally what this is
about.
Yes, there is a change in traditional Medicaid as well. And
we can argue about that. I mean, as Senator Graham said
earlier, if you do not do something on Medicare and Medicaid,
it takes up the entire budget within 30 years. I mean,
everybody, I think, acknowledges we have to do something on
entitlements, I hope. If not, we have to figure out an entirely
different way to get revenue in this country.
But even there, again, there has been some criticism from
the right saying, you know, this is essentially taking the
existing costs and continuing them. I mean, if you look at the
per-capita cap, that means that it increases by population, so
the traditional Medicaid does change, but it goes up by
population. But second, there is an annual adjustment by
inflation, and it is medical inflation and medical inflation
plus one.
What CBO projects for the rate of growth with regard to,
for instance, the blind and disabled category under Medicaid is
actually slightly less than what these guys are proposing for
their per-
capita program and the annual increase in Medicaid in that
category, because it is M and M plus one--3.7 percent.
So it is actually a proposal that has been a little bit
mischaracterized. But let me just talk about why we are here
then. I mean, what is the problem?
And you all hear it, because you all have individuals in
your States who depend on the individual market--small
businesses, families. I got an email from a guy named Dean. He
is a guy who lost his job back in 2009, he finally found a plan
that worked for him, then the Affordable Care Act comes in, and
he loses his plan. He is now paying, according to Dean, twice
as much for a plan that has less benefits for him and higher
deductibles.
Mike from Westlake told me recently, his health-care
insurance rate for single employees under 30 went from 198
bucks a month to 560 bucks per month. We just had a small-
business roundtable on Friday in Ohio. Health-care costs were
obviously a huge topic for them, and no wonder.
Joanne from Dublin sends an email saying she feels as if
she does not have health care at all because, under the
Affordable Care Act, her deductible has gone up to $11,000 for
a family. ``We will never reach that deductible,'' she says.
``I do not have health care.''
So here are the numbers from Ohio. And I do not know what
your States are like, but we just a couple of weeks ago
published the numbers for 2018: 34-percent increase. Who can
afford that? To these small businesses, what is our answer? And
so the status quo is not working.
And by the way, I agree with what Senator Carper said about
the CSRs, these cost-sharing reductions to be put in place to
help with stabilization. If we do that in Ohio, the insurance
companies say it will be a 23-percent increase. So it helps,
but it is still totally unacceptable.
So I guess to you, Mr. Smith, because you are one of these
experts who is dealing with this every day: can you explain how
this block grant model would help someone I have talked about
like Mike or Joanne or other folks in Ohio who are seeing their
costs just skyrocket under the Affordable Care Act?
Mr. Smith. Yes. Thank you, Senator. Again, I think that, in
giving the flexibility back to the States, I think we ought to
judge what States will do on what they have actually done. And
again, I would point out CHIP as being a very good expression
of that, where they had tremendous flexibility in defining what
the benefit package was, defining cost-sharing, et cetera, and
States put their efforts into competition, into good,
comprehensive health care, and also into trying to be as
efficient as possible with those.
Again, I think that, as I pointed out, the CBO got the
insurance pool so vastly wrong, because the subsidized pool
turned out to be much smaller and the Medicaid pool turned out
to be much larger. This proposal puts those pools together, and
bringing those healthy lives into a larger pool is what is
going to help stabilize premiums.
Senator Portman. Mr. Chairman, my time is expired. I look
forward to a second round of questions. I am going to talk more
about the formula. So we talked about the theory of getting
back--I do continue to have concerns, as you know, Dr. Cassidy,
on the formula, and I want to talk to you more about that and
how it affects the various States.
Thank you, Mr. Chairman.
Senator Roberts. Thank you, Senator.
Senator Cardin?
Senator Cardin. Thank you, Mr. Chairman.
I want to thank all of our witnesses for being here today.
I ask consent to put into the record, Mr. Chairman, letters
that I have received from people and groups in Maryland in
opposition to this bill.
Senator Roberts. Without objection, so ordered.
[The letters can be viewed on the committee's website.]
Senator Cardin. I want to point out that the process being
used here today--I want to just make it clear. We are 8 months
past the time Congress, the Senate, passed the budget that we
are now reconciling to with this amendment. We have finished
the debate time on the floor of the United States Senate. We
have had no committee markups, no chance for amendments. We do
not have a CBO score on Senator Cassidy's proposal.
We do know, though, that tens of millions of people will
lose their coverage, premiums will go up, and the quality of
coverage will go down. We do know that.
So, Ms. Miller, I want to concentrate on comments that have
been made here. Senator Cassidy, I think, correctly identified
the problem. We have a problem in the individual marketplace
with individuals who are not receiving subsidies. And all the
examples that Senator Portman just gave fall into that
category.
Now, in my State, I believe that is about 1 percent of the
population. Now, that is a significant number. I am not trying
to underestimate the problem. But could you just confirm
whether the numbers I am talking about are correct?
Ms. Miller. Yes, Senator. In Pennsylvania, we estimate that
that population is between 1 to 2 percent of the population. So
as you said, very small, but very important, because they are
buying coverage on their own, but very small.
Senator Cardin. So the proposal that is being brought
forward, though, will affect tens of millions of people,
because tens of millions of people are going to lose their
coverage, many others are going to lose the quality of their
coverage, and we are going to see significant cost shifting for
those who do not have health coverage.
Mr. Smith, I think, correctly analyzed what the States are
going to have to do. And I am going to use his language. He
says they will manage to the cap, and I think that is accurate.
States have budgets; they have to comply with their budgets.
States have already shown great initiative in delivery
system models to try to bring down costs and make the system as
cost-
effective as possible. So what is left to manage to the cap
seems to me to be two major factors: reducing eligibility,
cutting people off the Medicaid rolls, and then, since they no
longer have the mandate on essential health benefits,
eliminating certain benefits that are currently covered.
Are there other options available that I do not see?
Ms. Miller. When you are trying to cut the dollars out of a
program like we would be doing, you really only have three
levers. You can reduce the number of people receiving services,
you can reduce the services that you are providing, or you can
reduce payments to providers. And those are really your
options.
Senator Cardin. So that is how you manage to the cap. So I
am just going to--one of the individuals in Maryland whom I was
with today, Peggy Roche, was talking about her daughter who has
absence epilepsy. And she is very concerned. You gave some
genetic examples of families that have children that are born
with disabilities and how they are going to be at risk because
the State in managing to the cap may have to limit the amount
of services they provide to these high-cost individuals.
So we had today a New Jerseyan, Alison Chandra, who
identifies philosophically with pro-life, whose child was born
with a rare birth defect heterotaxy. There was not a dry eye in
the room as she explained what she is going through.
But she said she knew at least this Nation would take care
of her child so she would not have to go into bankruptcy, that
she had a protection that was out there. Are we not in danger
of losing that protection that is out there where we say every
child, every person is entitled to make sure that there are
benefits available? Is that not lost under this proposal?
Ms. Miller. I believe it is.
Senator Cardin. And I could go through those who are
suffering from the opioid drug addictions. We know before the
Affordable Care Act that the programs did not cover those
services. That is certainly at risk as the State manages to the
cap. Would you agree with that?
Ms. Miller. That is true. And I think it was brought up
that mental health parity stays in place, but mental health
parity does not guarantee access to coverage. It requires
parity if you have the coverage to begin with, but that would
not be guaranteed going forward.
Senator Cardin. As Senator Carper pointed out, this
proposal does not even deal with that 1 percent problem,
because there is nothing in this bill that shores up the
individual marketplace to deal with the specific problems that
those who are trying to repeal the Affordable Care Act continue
to monitor. These are real issues that we have to deal with.
And yes, dealing with the cost sharing, dealing with
reinsurance, dealing with the mandates, that will actually deal
with the problem, not this bill.
And what we put at risk--we all talk about our compassion
for those who suffer from cancer. But we know that some of the
treatments are pretty expensive. Managing to the cap is going
to limit the opportunities of those for young women who have
breast cancer, the type of treatments that will be available to
them.
I think that is what, Mr. Woodruff, you are saying is at
risk.
Mr. Woodruff. Absolutely.
Senator Cardin. Thank you, Mr. Chairman.
Senator Roberts. Senator Scott?
Senator Scott. Thank you, Mr. Chairman.
Thank you to the witnesses for being here today to discuss
this very important issue.
I have heard a lot today about stability and certainty in
the marketplace. And in South Carolina, that is a very
important issue. In 2014, we had nine insurers in the
individual market. And as we look at 2018, we will only have
two left in the market and only one in the exchange.
On top of the lack of choice in the marketplace, the South
Carolina individual market is seeing a 27-percent rate increase
in 2017. That does not sound affordable to me--a 27-percent
rate increase in 2017.
On top of that, we are looking at a 31-percent rate
increase in 2018. These rate increases are coming right out of
the paychecks of the average person in South Carolina.
Furthermore, the instability in the marketplace is so
severe that those who signed up in 2017, out of a hundred folks
who signed up in 2017, only 69 are still insured. In other
words, the stability and the certainty that we hoped for in the
ACA is missing. It is not missing in the future, it is missing
right now. Thirty-one percent of South Carolinians who signed
up at the beginning of the year simply cannot afford to
continue their coverage.
That is just the exchange population. But beyond the
exchange population, families--I spoke with one in Summerville,
SC, Brent, whose family pays $31,000 for their insurance. And
the ``A'' in the ACA stands for ``affordable.'' That is not
affordable at all.
And on top of that, we still have 136,000 South Carolinians
trapped in the coverage gap who are ineligible for any
insurance.
So when my friends on the other side demonize any effort to
take a look at anything other than the ACA--well, let us fix
it--they miss the obvious point that, for so many people today,
the ACA is not an option.
And yet my friends celebrate Romneycare. We are saying, why
not pass those decisions to every State to make decisions? And
if you look at all the polling information, one thing is clear:
residents and citizens throughout the entire country say that
their local and State politicians have their confidence more
than their Federal politicians.
This seems like a no-brainer to give the money to the
States to provide the very important opportunity to carve out
strong, reliable, affordable health-care options for their
citizens whom they see at the Piggly Wiggly, at the Walmart, at
the grocery stores every single night.
Mr. Smith, based on your experience and your expertise,
please delve into the issue of State flexibility and how this
could create lower premiums and allow more South Carolinians to
stay on their plan.
Mr. Smith. Thank you very much, Senator. And again, I think
that in many respects the States are the ones who understand
their own markets. There is no such thing as a national health
insurance market. Health insurance markets are statewide, and
even below that, they are local.
The idea that CMS--and again, they are my former colleagues
and I have the greatest respect for them, but to say that they
can manage every single market across the United States, again,
the examples that you have made show that that is not very well
done.
Senator Scott. We call that hogwash in South Carolina.
Mr. Smith. So to give back to the States the flexibility to
be able to make decisions, to adopt new tools that are on the
surface and--in some States that are trying to lead the way, of
helping, again, to manage to the cap, we now have managed long-
term services and supports models that we did not have
previously. We are now partnering with the private sector to be
able to manage the
highest-cost individuals who are out there in the fee-for-
service world, or what we used to call fend-for-self, the
highest-cost people having no one to coordinate their care,
having no one to help them.
Senator Scott. Thank you. I know that I am almost out of
time here. I figured Senator Cardin went over by about 63
seconds, I would just do the same. Thank you.
One last question for my colleague.
Senator Roberts. Okay, 23 seconds.
Senator Scott. Thank you so much, sir.
Senator Cassidy, to Senator Cardin's point which has to do
with opioids, can you share with us, amplify a little bit, how
the
Graham-Cassidy proposal would help those folks who are today
suffering under the weight of opioids?
Senator Cassidy. Mental health parity protections are
maintained per the current law. That is number one.
Number two, States have the ability to take this money and
to craft something which is particular for the opioid epidemic.
It does not have to fit into somebody in Washington, DC's
concept of what it should look like; it can fit into what that
State knows works and the locality in which it is needed.
Senator Scott. Thank you.
Senator Cassidy. Let the State have the ability----
Senator Scott. Thank you, sir. I wanted to answer that
question for Senator Cardin.
Senator Roberts. Senator Bennet?
Senator Bennet. Thank you, Mr. Chairman.
I am not sure quite where to start.
I can tell you this, to my Republican colleagues, and I
know they will disagree with this, Edmund Burke is spinning in
his grave at legislation like this. The kind of dislocation
this is going to create merely to keep a campaign promise to
repeal Obamacare is a disgrace.
The Senator was quite incorrect earlier when he said that
we did not have a bipartisan process in place. Ms. Miller has
testified to that. At the HELP Committee, we had a number of
hearings, both in the committee room and outside.
And I think, Ms. Miller, you said that there was actually a
consensus between Republicans and Democrats. Is not that
correct?
Ms. Miller. That is correct.
Senator Bennet. And what we were trying to deal with in a
conservative manner was to deal with the individual market,
which these folks are talking about having to be stabilized,
that is to say they have said it is destabilized--it is in many
cases destabilized--and that is what we are trying to address.
Is not that correct?
Ms. Miller. That is right.
Senator Bennet. And that is 7 percent of the people who
have insurance in this country.
Ms. Miller. Or less.
Senator Bennet. Or less. And of those, the ones who have
need of subsidies are even far less. Is not that correct?
Ms. Miller. That is right.
Senator Bennet. And I would say that all of our politics
for the last 9 or 10 years, almost, about health care has been
distorted as a result of trying to figure out what the right
answer for that 7 percent is. Would you agree with that?
Ms. Miller. Absolutely.
Senator Bennet. And now we are right at the moment where we
have bipartisan consensus on how to deal with that 7 percent,
and it is snatched away in favor of this partisan effort. Is
not that right?
Ms. Miller. That is right.
Senator Bennet. Or I will say that, you do not need to
agree with that. It is true. And sitting here listening to the
comments, the only thing I can come to is a conclusion that
says this is to keep a campaign promise to repeal Obamacare,
because in the bill we talked about in the HELP Committee,
Obamacare would not be repealed. Is not that right?
Ms. Miller. That is right.
Senator Bennet. And we might have to admit that it was not
actually a complete Bolshevik takeover of the United States
economy. You do not have to answer that.
And instead, well, let me ask you this, Ms. Miller. Is
there anything in this bill that is responsive to the
bipartisan testimony we heard in the HELP Committee?
Ms. Miller. Well, there is a 2-year reinsurance program. I
will tell you, that is not going to be enough to stabilize the
market.
Senator Bennet. Is there anything in your mind as an
expert, somebody who is an insurance commissioner, is there any
doubt in your mind that this bill will create massive
instability in the private insurance market for the 7 percent
of the people who are in that individual market?
Ms. Miller. There is no doubt in my mind that this will
create chaos.
Senator Bennet. And you will own that chaos, because if you
do not do what the consensus was with the CSR and with creating
some flexibility and having the mandate or some other idea to
have the mandate, you will get instability like you have not
seen before. Right?
Ms. Miller. That is right.
Senator Bennet. And so, why are we here, colleagues, making
matters worse? It is disgraceful. As all of you have said and I
will agree, there are things in the Affordable Care Act that
need to be fixed.
You know--and my view is this on that subject. Whether you
are for the Affordable Care Act or you are not has a lot to do
with whether you supported President Obama or not, not exactly
because there are people who had preexisting conditions before
who are now covered, but it tends to be that way.
But what I discovered in my State is, whether people
support the Affordable Care Act or whether they do not, they
are deeply dissatisfied with the way their family intersects
with the health-care system in America, with the way their
small businesses intersect with the health-care system in
America, because they know they are having to make choices that
nobody else in the industrialized world has to make because
this Congress cannot get its act together.
And right now when we have this issue staring right at us
in the individual market, we choose not to take any of the
recommendations that have been made in a bipartisan way in
hearings in the HELP Committee. And on top of that, we look for
an excuse to cut poor people off of Medicaid.
Do you think that about sums it up, Mr. Woodruff?
Mr. Woodruff. I think that sums it up very well.
Senator Bennet. Could I ask you, do you work for an
insurance company?
Mr. Woodruff. No.
Senator Bennet. Is the American Cancer Society an insurance
company?
Mr. Woodruff. No.
Senator Bennet. So let me just close by saying I cannot
believe the hypocrisy of people supporting this bill and saying
that they are fighting against insurance companies when what
they are doing is stripping hard-earned consumer protections
from the American people. It is a disgrace.
And what we should be doing is going upstairs to the HELP
Committee, continuing the bipartisan work that Ms. Miller
described, and addressing what is a serious problem in South
Carolina, in Ohio, and in Colorado.
As somebody who voted for the Affordable Care Act--and I
still have taken less time than Mr. Scott or Senator Cardin. As
somebody who voted for the Affordable Care Act, let me say for
the record, when somebody comes up and they say to me, Michael,
because of the bill you voted for, I have to buy insurance that
is too expensive for my family because I live in a place where
there is not enough competition and the price is high, the
deductible is too high, and when I call and I want my
insurance, for some reason it is never there because they can
have people stay on the phone longer than I can stay on the
phone; you caused that problem, fix it, I say to them, you know
what, your criticism is exactly right. We should fix it. Now is
our opportunity to fix it instead of playing politics with the
American people's health-care system.
Thank you, Mr. Chairman.
Senator Enzi [presiding]. Thank you.
And since Senator Cassidy is on the panel, our tradition is
that a panelist cannot question the other panelists in the
middle of a hearing.
So the next person would be Senator Casey.
Senator Casey. Mr. Chairman, thank you very much.
One of the more compelling pieces of evidence or testimony
in this whole debate has been what we have heard from folks
around the country, what we have heard from our individual
States.
We just had a--I do not know if Sara has that pile of
letters--but we had a series of letters delivered from the Arc
of Pennsylvania, just over the last couple of days, a pretty
hefty sum there, and then other letters that went to the
Finance Committee from Pennsylvanians and folks in other
States. So we are grateful for that.
I think the process here--I think even folks who are
supportive of this Republican bill would say that the process
is not in any way commensurate with the gravity of the
challenge and the scope of this legislation.
I would incorporate by reference what Senator Bennet said
about what has been happening in the HELP Committee, some of
the best bipartisan work on health care maybe in a decade,
moving towards a consensus and having four hearings just on
those very limited number of topics, nowhere near the scope of
this bill. And yet we had 2 weeks of hearings, great bipartisan
work.
We should return to that, get that bill done and then
maybe, I hope, move on to other issues.
I do not think there is any question--when you compare the
hearing time, either in the Finance Committee or the HELP
Committee, on the Affordable Care Act, there is obviously no
comparison. Once you get above one, of course, one hearing, you
are above where we will be tomorrow in this committee.
Eleven days of hearings in the Finance Committee over the
course of the consideration of the Affordable Care Act, 26
hearings in the HELP Committee. The final bill incorporated 147
Republican amendments--so, a stark contrast.
And then finally I would say that, in terms of process, we
could move in that direction and have a series of hearings on
this legislation or any other, but I know that there is a
deadline that some want to meet, which I think is not the
measure that the bill should be guided by, that September 30th
deadline, instead of working over months on a series of
hearings.
I have a couple of questions that I just have been
wondering about. And I will just throw them out--I guess more
statements than questions.
What I cannot understand is the obsession that Republicans
have on this committee, and it seems across the Congress,
against Medicaid or the hostility they have to Medicaid. I do
not understand it. It has gotten me very angry the last couple
of weeks and months because I care deeply about that program. I
want to protect it, to strengthen it, to preserve it. It covers
more than 70 million Americans, kids and people with
disabilities, seniors getting into nursing homes. I do not
understand that.
And I also do not understand, what is the big problem with
11 million people getting health care in this case through
Medicaid expansion, the balance getting health care through the
exchanges? Why is that a problem? Why is that wrong?
We all benefit when people gain health-care coverage. And I
think we are all diminished and in fact potentially injured
when they do not. Do we want 11 million people to not have
health care? Should that not be considered a measure of
progress?
Senator Toomey and Senator Santorum are here with us today,
and I welcome Senator Santorum back to the committee. They know
that in our State we have a huge rural population. We have 48
rural counties out of 67.
I spent a lot of time in the month of August going across
the State. And a lot of those trips were in those rural
counties. And talking to folks there just about the opioid
crisis, as Commissioner Miller, Secretary Miller, and others
have said, just that alone is a huge challenge in rural areas.
And in several counties, they said, thank God we have Medicaid
expansion. It is having the biggest impact on that problem, not
a magic wand, not solving the problem totally, but people in
Pennsylvania are getting treatment and services for an opioid
addiction problem solely because of Medicaid expansion. So I do
not understand the obsession with winding down and ultimately
getting rid of Medicaid expansion.
So let me get to some questions, because I know we are
limited in time; we will get another round, but I want to start
with Secretary Miller.
As Senator Bennet mentioned, you testified before the HELP
Committee. And when you reviewed the work that we were doing
there that you participated in, along with Governors and
others, and then when you reviewed this legislation, did you
find any evidence of the stability proposals that we were
working on in the HELP Committee? Did you find any of those in
this bill, the Republican bill that we are discussing today?
Ms. Miller. Senator, the only provision that we discussed
that I saw in this proposal is a reinsurance program that lasts
for 2 years. But it is not going to be enough to stabilize the
market without CSR funding, without the mandate, with the
repeal of the mandate. Those things are going to seriously
destabilize the market in 2018.
Senator Casey. And just very quickly--I want to be
observant of time, and I am over.
But, Secretary Miller, Pennsylvania expanded Medicaid. You
understand that better than most. This plan would block-grant
the Medicaid expansion funding in 2019 and eliminate the
funding entirely in 2027. Could you explain the impact this
would have on Pennsylvania?
And maybe on my second round I will ask, Ms. Mann, if you
could do that from a national perspective.
Could she answer that question?
Senator Enzi. Well, you are already a minute and a half
over. And we have a whole lot of people waiting.
Senator Casey. How about a short answer, can we do that?
Can I ask for a very short answer?
Senator Enzi. Yes, a short answer.
Ms. Miller. I think the impact of these cuts will be
devastating to Pennsylvanians. The Governor has done
everything, and all of us in his administration have worked
very hard to make sure we expand access to affordable coverage
for as many people as we can. And even if you look at the
conservative estimates, whether we are talking about $15
billion or $30 billion, which is our estimate, any of that
range is going to--those cuts are going to have a real impact
on people who rely on Medicaid for their health care.
Senator Casey. Thank you.
Thank you for indulging me, Mr. Chairman.
Senator Enzi. In the short time that I have been here, we
have had rapid escalation of the amount of time that Senators
are taking. I hope that some of the other people on both sides
will reduce their amount to make up for the extra time that
others have taken.
Senator Warner?
Senator Warner. Probably not. [Laughter.]
Thank you, Mr. Chairman.
Let me just make a couple of comments and try to get a
couple of questions in.
One, I have to give the sponsors of this legislation credit
for one thing. This is the most radical, the most audacious
change in our health-care system I think we have ever
addressed. What started as an effort to do away with
Obamacare--and let me add to the voices at least on this side
of the aisle that will acknowledge there are a lot of things in
Obamacare that need to be fixed and dealt with--has morphed
into a dramatic deconstruction of a program, of Medicaid, that
has existed for more than 60 years.
And I am not asking you to take the word of some wild-eyed,
Democratic, left-leaning liberal group. Let me just cite the
American Enterprise Institute, a well-respected, center-right
think tank. Their quotation as they go through the analysis,
talking to the sponsors and supporters of this legislation is,
quote, ``They should be mindful of the public perception that
the most important piece of domestic legislation in many years
is being pushed through Congress before there is time to fully
understand it or raise legitimate questions about it.''
Senator McCaskill is going to be up in a moment, and I do
not want to steal her thunder, but Standard and Poor's, not,
again, some wild-eyed, left-leaning group, has come out with an
analysis at 3:00 today that their first look or analysis of the
Graham-
Cassidy proposal indicates that over the next ensuing period it
would cost our country 580,000 jobs, $240 billion of lost
economic activity. Not some wild-eyed group, S&P.
I would say to my colleagues, good and radical ideas ought
to be debated. But if this is a good idea, it would be a good
idea 3 weeks from now after we had appropriate review. It would
be a good idea 3 months from now after we actually got to
hear--echoing what Senator Bennet said--from the hosts, not of
insurance companies, but of doctors, hospitals, State
advocates, the literally hundreds of people who are sitting
outside this hearing room, wanting to have their voices heard.
If this is such a great idea, let us take the time to
analyze it, review it, and put it through all the same hoops
that Obamacare went through. Chances are there might be
Democratic amendments that would actually be accepted. But no,
we are going through this trumped-up process to try to get a
political scalp before September 30th.
I also would say, clearly, some of the sponsors--and I have
great respect for all of them--but none of them has ever been a
Governor. Now, Senator Carper and I have been Governors. We
have had the responsibility at the State level to try to
implement massive programs and changes.
Our legislature meets in a short session. We get a new
Governor coming up, we only have a 4-year term in Virginia,
unfortunately, but we had a new Governor come January. The
notion that a new Governor with a fresh legislature could
redesign a whole health-care delivery model, submit it by March
of 2019, and that this administration could somehow provide a
host of waivers between then and 2020 is obviously put together
by somebody who has never run a program or surely never run a
State.
And again, do not take my word for it. The National
Association of Medicaid Directors said, again, quote, ``Taken
together, the per-capita caps and the envisioned block grant
would constitute the largest intergovernmental transfer of
financial risk from the Federal Government to the States in our
country's history.''
And quite honestly, to those of you who are sponsors of the
legislation, I think most State legislators and most Governors
ought to weigh in. And why, if we want to do this kind of
process, why would we not invite Governors? Let us invite
Republican Governors here to weigh in on this legislation
rather than trying to jam it in before some arbitrary deadline.
And, Mr. Chairman--I will not get to my question because I
will try to honor my 5-minute time--I have to join my
colleagues. I believe strongly in a bipartisan process. I think
I have the scars to prove it from previous actions where I was
willing to take on entitlement reform. But this current process
is a travesty.
Senator Enzi. Next is Senator Cantwell, followed by Senator
Brown, and then Senator Isakson.
Senator Cantwell. Thank you, Mr. Chairman. I was hoping
that Senator Hatch would be here. And I just wanted to take 30
seconds to say, as critical as this situation is, and I view it
as very critical, I also view the situation in Puerto Rico as
very critical.
I would hope that our colleagues would work hard to make
sure that there is a Federal FEMA declaration for all of Puerto
Rico, every county. And I would hope that our colleagues would
work very diligently to encourage the White House to appoint a
lead at the White House, perhaps a czar, to work with all
Federal agencies in coordination.
I know Senator Hatch cares a lot about the health-care
issue, but these are issues that are going to take a long time
for us to recover from, and I hope our colleagues will work to
encourage such coordination at the White House level. Thank
you.
On this subject, I am having a tough time understanding the
overall philosophy of this legislation. I can say that I
definitely had town meetings and was encouraged by the fact
that Senator Cassidy wanted flexibilities for States. I was
encouraged. I think I even mentioned it that he wanted
flexibility.
But the reason why we are not working together now on this
legislation is because it is taking the premise of flexibility
and turning it on its head as it relates to a program that has
been a 52-year relationship between the States and Federal
Government. It is taking a 70 million population and basically
saying, I am going to change the way health care is delivered
to you under the ruse that you are trying to address the
individual market, which is 18 million. So you are trying to
say to people, I am fixing that in the individual market, when
you are not. States that expanded Medicaid have 7-percent lower
premiums in the individual market.
And the notion that we should do this because of TANF, that
TANF was some sort of lifeline, the TANF experiment--and I
should bring up, your State is the lowest in the Nation in per-
capita TANF benefits in the sense of, for every hundred people,
you serve the least TANF benefits. What has driven people out
of poverty in America is not the way we structured TANF, it is
the EITC, it is the SNAP program. That is what has helped.
And so now you take this block grant experiment and say
that you are going to somehow magically drive down costs in
health care when in reality you are just kicking millions of
Americans off with the ruse of putting them into a capitated
program and then cutting their benefits.
So to me, it is not a panacea for the future. I would love
to see--oh, by the way, you take the one creative, flexible
idea that States have, section 1331, that has allowed 650,000
people in the State of New York to get cheap, affordable health
care at $500 a premium, and X that out. So you took one of the
most creative ideas that will cost New York billions, probably
$3 billion to $4 billion, because you have X'd it out.
So my point is this, to Ms. Miller. I am pretty sure there
are innovative ways in the Affordable Care Act to drive down
costs. I am pretty sure your State, Pennsylvania, took
advantage of them. I think you helped expand a program to get
people off of nursing home care and to community-based care. In
our State, that saved billions. I am pretty sure that probably
will save a lot of money in Pennsylvania.
What about those ideas for driving down the cost of
Medicaid? Because my colleagues on the other side, I think,
seem to think the only way that you can drive down the cost of
Medicaid is cutting people off. And I totally disagree.
In fact, I think this chart raises the question on health
care in rural America. The non-expanded States have seen the
most closures of rural hospitals in America. Why is that? Why
is that?
So the notion that somehow we have, in the corner of
Graham-Cassidy, figured this out, I just do not believe it.
So do we have innovation in the Affordable Care Act that is
driving down costs in the Medicaid market in a very significant
way, and can we push it faster?
Ms. Miller. Thank you, Senator. I think you are alluding to
our Community Health Choices program that we are rolling out. I
think we all know that seniors want to be served in their
communities. And I think our Governor has made a real push to
get people out of nursing homes and let them age in their
communities.
And we also know that, in terms of the costs to Medicaid,
it is mandatory in terms of paying for nursing home services,
but
community-based services are not mandatory. And yet, moving
people out of institutions and into the community is how we are
going to save money for both the States and Federal Government.
Senator Cantwell. Thank you.
Thank you, Mr. Chairman. Thank you.
Senator Enzi. Thank you.
Senator Brown, then Senator Isakson, and then Senator
McCaskill.
Senator Brown. Thank you, Mr. Chairman.
These are 200 of the literally thousands of letters and
emails that my office has gotten recently in opposition to this
plan. I would like unanimous consent, Mr. Chairman, to enter
these in the record.
Senator Enzi. Without objection.
[The letters can be viewed on the committee's website.]
Senator Brown. Mr. Chairman, thank you.
I appreciate what Senator Bennet said a moment ago about
the discussion from the other side on, their words, the failure
of Obamacare. It has been centered on 7 percent of the market,
and not even on 7 percent, more like 1 percent who are not
getting subsidies. So the importance of--I think it really did
answer the dishonest kind of opposition to the Affordable Care
Act in what has been happening.
But something else was said a moment ago. One of my
colleagues said there is a coverage gap of 30,000 people in his
State who simply are not getting insurance, that the Affordable
Care Act has not taken care of. Well, the fact is in his State,
his Governor did not expand Medicaid. That is the reason he has
the coverage gap, the coverage trap, whatever term he tends to
use.
And I am proud that in my State, a Republican Governor,
John Kasich, did in fact expand Medicaid; 700,000 people--
700,000 people--in my State have health insurance because the
Governor did that. Two hundred thousand people right now in
Ohio are getting opioid treatment because of Medicaid, because
of the expansion of the Affordable Care Act, something that
none of us on this committee should forget.
Now, Mr. Cassidy, you sort of answered this question about
opioid treatment. And I want a more direct answer. Included in
the BCRA was $45 billion specially requested from some of us on
this committee for opioid addiction treatment. Is there a
provision--I need a ``yes'' or ``no'' answer--is there a
provision in your bill, a similar provision with dollars
specifically targeted for opioid treatment?
Senator Cassidy. It is in the flexible block grant. States
can choose to spend that as they wish. And I presume in your
State they would.
Senator Brown. Okay. I guess I would take that as a ``no,''
because I quote The Columbus Dispatch, a generally very
conservative Republican paper, the State's second largest,
which says, ``This bill does not specifically include money to
treat the epidemic of opioid addiction.'' It goes on to say,
``This study suggests lawmakers in Columbus would have to find
billions of new State tax dollars to maintain current levels of
health care for people receiving Medicaid.''
And I also listened to what Governor Kasich said, who is
the Republican Governor of my home State, as I said: ``First,
more than eight people in Ohio likely will die today, if this
is a typical day, due to an opioid overdose. We tragically lead
the Nation in the number of people who died in the course of
the last couple of years from opioid overdose.''
Governor Kasich's press secretary said, ``Make no mistake,
losing billions of dollars would be devastating to Ohio as we
work to provide care to our State's most vulnerable and drug-
addicted. The only ones who can support this legislation are
those who have not had time to properly assess the damage it
would do.''
And as my colleagues have pointed out, you certainly, Mr.
Chairman and Senator Hatch and Republican leadership, have not
given us the time.
As Senator Casey said, he and I sat on the HELP Committee;
150 Republican amendments were accepted. The hearings went on
for weeks and weeks and weeks in that committee and this
committee. Nobody is going to have time. You can say the bill
is shorter than the Affordable Care Act, okay, big deal, but it
has not been analyzed--we know that.
But do not take my word for it. I was at the Talbert House
in Cincinnati meeting with a group of people about opioid
treatment. A father sat there with his 31-year-old daughter. He
turned to me and touched her on the shoulder and said she would
not be alive now if it were not for Medicaid. Or the sheriffs--
I met with a group of sheriffs in Columbus at a training center
this week. Those sheriffs talked about the importance of opioid
treatment and other things that they need to do. Or a woman in
Youngstown who said her son is getting treatment today because
of Medicaid.
We know the importance of that. We know this Graham-Cassidy
bill does not at all address the issue of opioid treatment, of
treatment paid for by Medicaid.
So my question is, Ms. Mann and Ms. Miller, will States
have the tools, in your mind, to fight the opioid epidemic if
we adopt this bill?
I will start with you, Ms. Mann.
Ms. Mann. They will be losing the Medicaid expansion
dollars. They will be losing even the ability to cover those
individuals with regular Medicaid matching dollars. So that
source of incredible, important funding for services will dry
up. And it is easy--and that is the danger of a block grant--to
say, well, not a problem because, in fact, you can take some
money out of the block grant to address the opioid crisis. You
can take money out of the block grant and you can provide
coverage to everyone and you can solve all the problems in the
marketplace.
The fact is, the money is not there to be able to do all of
those important goals.
Senator Brown. Ms. Miller, if Graham-Cassidy is passed,
will more people die of opioid addiction or something else?
Ms. Miller. I am concerned they will, because I do not
think we will have--with the reduced funding, Governors are
going to have to make very difficult decisions, and some of
those decisions may be eliminating essential health benefits
like substance abuse treatment.
And before the ACA, I think it is worth noting, oftentimes
people could not access substance abuse treatment because it
was often a benefit, particularly in the individual market,
that was not covered.
Senator Brown. So you see in Columbus and in Harrisburg and
in Lansing--just to comment really quickly, Mr. Chairman, you
took 20 seconds of my time at the beginning when I asked for
unanimous consent on this, I am just taking it back if you do
not mind----
Senator Enzi. It was not 20 seconds.
Senator Brown. You can see in Columbus and Harrisburg and
Denver and Jeff City, you can see lobbyists for nursing homes
fighting with advocates for children's hospitals, fighting with
opioid addiction counselors for those declining dollars, those
scarce dollars that now are generally available, but will not
be in those days.
Ms. Miller. That is exactly the problem.
Senator Enzi. Senator Isakson, followed by Senator
McCaskill, followed by Senator Toomey.
Senator Isakson. Thank you, Mr. Chairman.
Just to make a point, Senator Casey, I want a ``yes'' or
``no'' answer. Is it not true that you recently cosponsored a
bill with a Republican legislator to create priority review
vouchers for rare childhood diseases, and 2 weeks ago the first
drug under that program was approved that now cures a certain
type of cancer for youth? Is it not true you did that on a
bipartisan basis?
Senator Casey. I did, and that Senator is a good man.
Senator Isakson. The reason I mention it is, I have been
here the whole time, I have listened to accusations about all
this, give me ``yes'' or ``no,'' you always know it is a loaded
question. But ``yes'' or ``no,'' we do a lot of things together
as Republicans and Democrats that we do not tell the public
about. So I thought I would leave the hearing with one piece of
good news after having the hearing today. Thank you very much.
Ms. Miller, Mr. Smith, my State has 159 counties. Next year
we will only have one carrier in 96 of those 159 counties. Do
you have this similar type of decline of available carriers for
your citizens under the Affordable Care Act?
Ms. Miller. Senator, for Pennsylvania, actually, we did
lose a few carriers, but we still have five insurance companies
in our market. And this year, at the beginning of the year, we
heard from all of those carriers that our individual market was
stabilizing. And when we received the rate filings, those rate
filings averaged 8.8 percent. They will not be that in a week
or so when we end up approving rates because of all the
instability coming from DC, but if the world stayed the way it
is today for next year and all of these discussions went away,
in Pennsylvania our market is stabilizing and we would see 8.8-
percent increases.
Senator Isakson. To what do you attribute the fact that you
are not losing and in fact are seeing stabilization, pending
what we may do up here? To what do you attribute that?
Ms. Miller. The market is stabilizing. The ACA included 3-
year programs. Two of the premium-stabilization programs were
3-year programs. I think those who developed the ACA recognized
that when you change the world, like you do, you change all the
rules, you get a new population covered, it is going to take a
few years to stabilize.
And I think what we saw is exactly what those drafters of
the ACA thought. After 3 years, in 2017, our market is
stabilizing.
Senator Isakson. Mr. Smith, what is Arkansas State going to
be?
Mr. Smith. Arkansas has three carriers Statewide. We hope
to attract more. We hope to do that by building on competition
and inducing new ways of a service delivery system. We are
developing an entirely new service delivery system on the
Medicaid side of things.
And again, part of my concern is, we have gotten bogged
down into false choices about, you have to cut this or you have
to cut that or you have to cut that. If we started doing things
smarter, if we started doing things that inject competition--we
are developing an entirely new form of organized care, an
organized care model in which providers are accepting risk.
These are the things that invite us to be able to make Medicaid
sustainable for the long run for both the States and the
Federal Government.
We have to do things differently in Medicaid. And it is a
false choice to simply say, well, all you have to do is cut
benefits, all you have to do is cut eligibility. I believe we
are demonstrating more ways to do things better that are better
for the individual, the people whom we have been talking about,
the people with developmental disabilities, people with mental
illness, who are the least capable of being able to maneuver
through a fee-for-service system. We are organizing care around
them that will keep them out of the hospitals, people in our
nursing home populations.
We put together in 2005--the Deficit Reduction Act of 2005
included a provision called Money Follows the Person. That was
a Republican idea to help get people out of institutions and
back into the communities.
So there are a lot of ideas. Unfortunately, I do not think
we have really talked about any of the ideas that we can do to
make the program sustainable, to continue to serve people, and
in the manner they choose to be served.
Senator Isakson. Thank you very much.
Senator Cassidy, do you remember the date that you
introduced Cassidy-Collins?
Senator Cassidy. I do.
Senator Isakson. What was that date?
Senator Cassidy. Well, I cannot remember the exact day, but
I remember the kind of----
Senator Isakson. Approximately, what day was that?
Senator Cassidy. Oh, probably now, man, 10 months ago or 8
months ago? I am sorry, I do not remember the exact date.
Senator Isakson. For the record, I wanted to ask that
question because if you had listened to a lot of the questions,
you would have thought it was introduced last week and tonight
is the only time we are going to talk about it. But in fact,
your original concept, which was Cassidy-Collins, was
introduced almost a year ago, and it has been worked on during
that period of time by you. And I was a cosponsor of that
legislation about 6 months into that period of time. Is that
not correct?
Senator Cassidy. Yes, sir.
Senator Isakson. Well, I thank you for your leadership.
Thank you very much for the opportunity to ask questions,
Mr. Chairman. I yield back.
Senator Enzi. Thank you.
Senator McCaskill, followed by Senator Toomey.
Senator McCaskill. Thank you, Mr. Chairman.
Let me briefly go through what the S&P said this afternoon
at 3:00 on insured levels, lower levels of insured. On the
macroeconomy, as has already been mentioned, 580,000 lost jobs,
$240 billion in lost economic activity, ensuring that GDP
growth remains stuck in low gear of around 2 percent, at best,
in the next decade--2 percent GDP, at best, in the next decade.
U.S. States' increased flexibility comes with fewer Federal
dollars--this is the S&P that has done this analysis--creating
increased fiscal and operational burdens on the States.
Insurance industry: increased uncertainty in the short term
with repeal of the mandate and lack of clarity around cost-
sharing reductions.
AEI--I do not typically read a lot of AEI, but I read this
article because I thought it was really interesting. I am just
going to read two short portions from the American Enterprise
Institute which typically would not be read from this side of
the room, typically. ``Although an important policy goal for
Republicans is to lower premiums in the individual market,
Graham-Cassidy, like the BCRA, is likely to have the opposite
effect. Because Graham-Cassidy is so complex and far-reaching,
we believe more time is needed to understand and debate its
merits. And the legislation would benefit from a traditional
markup in committee where serious amendments could be
considered. Moving too fast risks significant unintended
consequences and public resentment.''
Now, moving too fast means that, when I got on the plane
this morning, I thought I knew what the bill said. When I got
off the plane, it did not say that anymore.
And an important change--I have not had a chance to read it
all; my staff tells me this is one of the changes that was
made. I have not had a chance to digest all of them, but one of
them is we have now moved, in terms of legislative history and
the litigation that will occur around this legislation--I can
assure you there will be plenty of it--they will look at
legislative history. In the legislative history, in every
version of the bill until now, the States applied for a waiver.
No more waiver now. Now the States just have to give a
description of how the State shall maintain access to adequate
and affordable health insurance coverage.
And I cannot find, Senator Cassidy, where ``adequate and
affordable'' is defined anywhere. Is there a legal definition
of ``adequate and affordable'' in this bill?
Senator Cassidy. There is a Merriam-Webster definition of
affordable; it means you can afford, as opposed to the $39,000
premiums in the ACA for those in the individual market.
Senator McCaskill. That is not my question. Is there a
definition of either----
Senator Cassidy. But it is the answer.
Senator McCaskill [continuing]. ``Adequate'' or
``affordable'' in the bill?
Senator Cassidy. Nor is there a definition for the word
``and''--a-n-d.
Senator McCaskill. Okay.
Senator Cassidy. It is an accepted definition, a-n-d.
Senator McCaskill. Well, we did a lot of things around
health care where we tried to set some limits as to out-of-
pocket and all of those things. None of that is in the bill.
Also, there is now no waiver for the essential health
benefits. You can just waive them. I mean, you do not have to
ask for permission anymore. The essential health benefits are
now gone, there is no waiver necessary. So the essential health
benefits, like maternity care, like prescription drug coverage,
like addiction coverage, I understand you can say, well, the
States can use the money we are giving them to do that, but we
are asking them to do more with less.
And so the question I have for you is, when the State calls
and says, this is what we are going to be able to do, and I
guess CMS says, well, that is not good enough, and the State
says, well, we have to have more money to do what we need to
do, that is it, right? I mean, there is no more money, right?
It is capped.
Senator Cassidy. First, Missouri has lots more money,
because you are a non-expansion State and you would be treated
as if you were an expansion State. So in your State, there
would be lots more money.
Senator McCaskill. Let me talk about expansion States.
Senator Cassidy. Sure.
Senator McCaskill. You said earlier in the hearing, well,
we just assume Governors will want to take care of the people
in their State.
Senator Cassidy. Yes.
Senator McCaskill. Well, I have been painfully watching in
my State when the people in charge in Jefferson City, who would
be in charge of this program, made a decision to turn away
billions and billions of dollars that the citizens of Missouri
were entitled to for health care, acting against their own
self-interest because of politics.
Senator Cassidy. This bill gives it to them.
Senator McCaskill. I understand it, but you act as if they
are always going to do the right thing for their people. A lot
of these States said, no, we do not even want the Federal money
to help more people with health care, we are going to turn away
the Federal money to help more people with health care. Now you
believe that all of a sudden there is going to be a change of
heart and they are going to be stretching every dollar? And why
can't we do waivers now?
Senator Cassidy. The problem was that States were not sure
that they could afford the match. Ms. Miller has said that
there is going to be a problem in Pennsylvania with their State
budget, and that, in part, is driven by the 10-percent match
required by the Medicaid expansion.
We waive that so States who feared they could not cover the
match now get the dollars without the match; they get the best
of both worlds.
Senator McCaskill. They are cutting Medicaid providers in
my State right now without--without--expanding Medicaid. They
are cutting providers right now. And I understand the State is
in a tough position, because they have a balanced budget
amendment where they have so many dollars and they only do so
much.
So I guess this is my final question. There is a 27-year-
old man--the mandate is gone. I have been lectured about
personal responsibility by some of my friends across the aisle
during my career. A 27-year-old man, he can either afford a
health insurance premium or a Harley. He buys the Harley, there
is no more mandate. He puts it on the pavement, he is life-
flighted to a hospital in Kansas City or St. Louis, he is given
millions of dollars of health care, because we do not stop them
at the emergency room door and say, sorry, you did not buy
health insurance. He is bankrupt in 10 minutes. Under your
bill, who pays that bill?
Senator Cassidy. Under our bill, he could be automatically
enrolled so that he would automatically be insured. By the way,
Missouri would get $4 billion more from 2020 to 2026 to do that
sort of thing.
Senator McCaskill. Wait a minute. So everybody is going to
get insurance if they do not buy insurance?
Senator Cassidy. You could automatically enroll them if you
wished; you have that flexibility.
Senator McCaskill. So under your bill, nobody has to buy
insurance until they show up at the hospital?
Senator Cassidy. No, no. The State could--just like on
Medicare when you turn 65 you are automatically enrolled in
Medicare--the State could decide that folks who are eligible
are automatically enrolled. They may give them a policy with a
high deductible and a catastrophic----
Senator McCaskill. He is 27 years old.
Senator Cassidy. Yes. And so the State might say, you are
in the pool. If you do not want to be, give us a call, you do
not have to be. But if you do not call us, we are going to
assume----
Senator McCaskill. On the second round, I want to see how
this works that somebody can get insurance when they show up--
--
Senator Cassidy. Wonderful. Thank you.
Senator Enzi. Senator Toomey, followed by Senator Heller.
Senator Toomey. Thank you, Mr. Chairman.
I recall that none of the panelists suggested to Senator
Grassley that Medicaid's growth rate is not on a sustainable
path. Of course, that has been the case for a very long time.
And it was observed previously this afternoon that the Graham-
Cassidy-Heller-Johnson bill and previous Republican bills are
not the first attempt to restructure Medicaid in a way that
would put it on a sustainable path.
In fact, in 1996 the Clinton administration proposed an
aggregate cap on all Medicaid beneficiary categories and
proposed further that those caps would grow at a rate of per-
capita GDP, but not at the rate of medical inflation.
They also proposed that it would go into effect 6 months
from the date at which it was first proposed. It was supported
by the American Academy of Pediatrics; the chairman of the
National Governors Association, Howard Dean, who praised the
idea of these caps; the National Association of Public
Hospitals, now known as America's Essential Hospitals; and
Secretary of Health and Human Services Donna Shalala.
And interestingly, in December of that year, every single
Democratic member of the Senate sent a letter to President
Clinton saying, and I quote, ``We express strong support for a
per-capita cap structure.'' That would include Senator Murray,
Senator Leahy, Senator Feinstein, as well as every other
Democratic Senator at the time.
It is worth noting that, unlike the Graham-Cassidy
proposal, the Clinton proposal did not phase in over 8 years,
it phased in in 6 months. The Clinton proposal did not include
bonus payments for high-quality delivery of care, it did not
exclude the medically complex children, all features in the
Graham-Cassidy bill.
Now, some things have changed since the 1990s. What has
happened with Medicaid? Well, it has grown enormously. Medicaid
was then less than 6 percent of the Federal budget; now it is
10 percent. Medicaid now is the single-largest net Federal
expenditure from general revenues. Other large programs have
dedicated revenue streams; Medicaid has none. And CBO continues
to project that it will far exceed the growth of the economy.
Despite the fact then that Republicans have adopted a
Democratic idea and proposed a Democratic idea, we have
colleagues who are suggesting that these ideas are cruel,
obscene cuts, that it constitutes a war on Medicaid, that it is
an attempt to decimate the program.
Colleagues, I understand changing your mind. I understand
abandoning the reform that your party once unanimously
embraced, at least at the level of the United States Senate. I
understand deciding that you are not interested in entitlement
reform anymore.
But when you attack the character and the motives of
Republicans who have proposed your proposal, actually a gentler
and more generous version of the proposal that once had
unanimous Democratic Senate support, when you malign the
character of us for doing that, it diminishes the credibility
of this message that you so much want to work together on a
bipartisan basis to get this stuff done.
Senator Cassidy, let me ask you a couple of questions, if I
could. We have heard a lot about the devastating spending cuts
to Medicaid. In what year does Medicaid spending begin to get
cut?
Senator Cassidy. For almost every State, 2027, not because
the block grant is not reauthorized, CHIP is always
reauthorized. And some of these studies claiming 32 million
insured assume that all the money goes away in 2027. No,
because that is the time in which States' costs actually
inflate to the caps.
So they will have 10 years to adjust their health-care
delivery systems so as to respond to the caps.
Senator Toomey. Mr. Smith, if I understood you correctly,
the elderly category of Medicaid recipients, that category,
that per-
beneficiary cap under this legislation grows at the rate of
medical CPI plus one for a number of years and then at some
point the growth rate switches to medical CPI.
Did I understand you to say that CBO is projecting that the
actual cost increases are projected to be less than the growth
in the caps under the Graham-Cassidy bill?
Mr. Smith. That is correct, under their most recent
baseline, yes, sir.
Senator Toomey. So the Graham-Cassidy bill establishes a
cap, allows it to grow at a rate that CBO does not think we are
even going to reach.
Mr. Smith. That is correct.
Senator Toomey. That is correct. But yet, that is a cut.
Okay.
I see I have--do I have time for one more question?
I will save it for the next round. Thank you, Mr. Chairman.
Senator Enzi. Thank you.
Senator Brown. Mr. Chairman, I just want to interject that,
comments notwithstanding from the panel, CHIP expires this
Saturday. So let us not pat ourselves on the back until we
actually do that if we are going to brag about CHIP.
Thank you, Mr. Chairman.
Senator Enzi. Senator Heller, followed by me.
Senator Heller. Mr. Chairman, I want to thank you and the
ranking member for holding this hearing today on Graham-
Cassidy-Heller-Johnson. And I want to thank my colleagues,
Senators Cassidy and Graham, former colleague Senator Santorum,
and Senator Johnson, for their leadership on this particular
proposal.
And when these Senators came to me with an idea that would
fundamentally change the way our health-care system works, when
they told me that this plan offered Nevada more flexibility and
more funding to meet the needs of our patients, I said ``Sign
me up.''
Our proposal represents what I set out to do from the very
beginning of this summer's health-care debate, and that is to
do what is best for the State of Nevada, the citizens in our
State and across this country. And we all know that Nevadans
and Americans across this country are facing higher costs and
fewer choices under Obamacare.
As a small-government conservative, I believe any solution
to our broken health-care system needs to be rooted in
increased flexibility with a goal of enhancing affordability
and access to coverage. A one-size-fits-all approach is not the
answer. So what is the alternative? That alternative is to
remove Washington from the
decision-making process, allow a 50-State solution where each
State is empowered to do what they think is best on behalf of
their patients.
In fact, 2 weeks ago I held a telephone town hall meeting
where I heard from a nurse in Las Vegas who is also a patient
advocate. She brought up the Graham-Cassidy-Heller-Johnson plan
and said she is glad people in Washington, DC finally get it.
She agreed that it is essential to bring health-care decisions
down to the State and local levels to improve the quality of
care in this country.
Our proposal takes Obamacare funding and replaces it with a
block grant given annually to States to help individuals pay
for their health care. This plan gives States the flexibility
to innovate and create health-care systems that will lower
premiums, expand coverage, and allow States to serve their
Medicaid population as they see fit.
This proposal presents States with many options for coming
up with a tailored approach most appropriate for their
citizens. For example, States like Nevada that have expanded
Medicaid can continue serving this population with their block
grant dollars. And because Nevada will not be on the hook for
the 10-percent match required under Obamacare in 2020, the
State will save $1.16 billion.
As someone who recognizes the increased needs within our
State as a result of the State's decision to expand Medicaid,
these provisions are critical.
Our proposal also allows States to use up to 20 percent of
their block grant dollars on traditional Medicaid, providing
States with additional flexibility to serve individuals who
rely on this program.
Understanding that Nevada is committed to providing
affordable, quality care to our patients, including the most
vulnerable, our proposal allows them to advance these efforts.
For example, Nevada can enter into arrangements with insurers,
including managed-care providers, to continue its commitment to
vulnerable patients as well as ensure that Nevadans who rely on
Medicaid have access to the services that they need.
Under this proposal, States can also access additional
funds that will allow them to address urgent health-care needs
at home. These are just a handful of examples of how States can
benefit from this proposal through increased flexibility.
Senators Cassidy, Graham, Johnson, and I believe that our
plan is the best path forward to address our Nation's health-
care challenges. So I am grateful to the chairman for allowing
us this opportunity.
A quick question to you, Mr. Cassidy. Could an expanded
State like Nevada use the money to replicate their current
Medicaid expansion system?
Senator Cassidy. Absolutely. Senator Heller, folks say you
are losing the Medicaid expansion dollars. No, you still get
them; you just get them in a flexible block grant. And if you
wish to fund opioid services, you can fund opioid services. If
you wish to do something good to decrease to transmission of
HIV, you can do that as well.
So absolutely, you pegged it: you can keep the money, you
can keep on doing what you have been doing, if you wish.
Senator Heller. It was mentioned earlier that 40 percent of
Obamacare dollars are spent on four States: California,
Maryland, Massachusetts, and New York, and they only represent
22 percent of the population. Do you think this speaks to an
equity issue inherent in the current system?
Senator Cassidy. It does. And as a doctor who worked in the
public hospitals of Louisiana for so long trying to bring
services to those who do not have insurance, the idea that you
could somehow give these folks in an orange State equity, no
matter where you live, you can still have access to the same
level of support from the Federal Government and your State
does not go bankrupt because it has to come up with a match--
which Ms. Miller tells us that Pennsylvania is going to have a
hard time doing--because we waive the match, we think we get to
where we need to be.
Senator Heller. Does this legislation give Nevada more
dollars with more flexibility?
Senator Cassidy. Correct.
Senator Heller. Thank you.
Mr. Chairman, thank you.
Senator Enzi. Thank you.
And I am going to switch places with Senator Thune who has
another engagement.
Senator Thune. Thank you, Mr. Chairman.
And I think we have heard discussions today about how this
is going to create chaos. And I think it kind of depends on
what your definition of chaos is.
In my State of South Dakota, we have seen premiums increase
by 124 percent since 2013 in the individual marketplace. We
once had 17 carriers in that marketplace; we now have two. And
almost half the counties in America this next year are going to
have one--one--option when it comes to buying in the exchanges,
in the individual marketplace. That, to me, seems like the very
definition of chaos.
And I think what the gentleman from Louisiana and his
colleagues are trying to do is to try to bring some order to
that chaos. And I thought that the Senator from Pennsylvania
covered very well the history of per-capita caps.
I have also heard some of my colleagues from the other side
talk about how radical these ideas are, so radical that
President Bill Clinton and congressional Democrats proposed
this back in 1996--per-capita caps.
Block grants to States--it is something that has been
talked about around here for a long time. And it has worked; it
has been successful on some level. And you know, in terms of
the complication of this bill, this bill, in its current form,
is 146 pages long--146 pages. Obamacare was 2,700 pages.
I think this is a very good-faith effort to try to solve a
problem we all know has to be solved, and that is that we have
an individual market that is in freefall. And so I give great
credit to the sponsors of this bill for trying to fix this
problem and trying to eliminate some of the chaos that exists
in the individual marketplace today and trying to reform a
program that we all know is unsustainable.
So, Dr. Cassidy, your proposal has been developed based on
feedback from Governors, correct?
Senator Cassidy. Correct. Fifteen Governors have signed a
letter in support thereof--18, I am sorry.
Senator Thune. And it would be my belief--and I cannot
imagine it would not be shared by most of the people here on
this panel--that there are going to be some unique needs in
individual States. Everybody has different populations. And we
have always, you know--the assumption of Obamacare is that the
one-size-fits-all approach from Washington, DC is best. And we
now know that does not work. Higher costs, higher taxes, fewer
options--that is the legacy of what we have.
So why not try something different and something that we
think has a record of success? It has been implemented in the
past with welfare reform.
And so I guess my question is, based on the conversations
you have had with some of these Governors, how do you expect
States to use their block grant dollars and their ability to
waive certain regulations, based on the feedback that you are
getting from Governors?
Senator Cassidy. Well, the Governors are excited about it.
They see this as the ability to implement change that is
tailored for their State as opposed to, again, the kind of one-
size-fits-all.
Mr. Smith spoke about a couple of things. And Arkansas has
been very innovative. But if you have an unstable individual
market because there are too few people in the individual
market for actuarial stability, you can combine that with your
Medicaid expansion population, the bigger pool providing
stability for the older and sicker, and premiums could go down
by as much as 20 percent.
You could also do what Maine did, which the Affordable Care
Act told them to shut down, the so-called invisible high-risk
pool, where there is reinsurance the patient does not even know
exists. They still have the care management from the insurance
company, but just that itself, according to Susan Collins, who
knows insurance so well, lowered premiums by 20 percent.
Ms. Miller kept speaking as if there are only three ways to
lower costs. She is absolutely wrong. You could actually put in
policies. In Maryland, there is such market concentration of
hospitals, there is no competition, and so hospitals charge
very high rates. If you started to go after market
concentration, you could lower the health-care costs, because
market concentration leads to higher costs.
I could go on, but the Governors who are creative can think
of all sorts of things.
Senator Thune. And very quickly, Mr. Smith, you have
written past papers about the need for maintaining State
flexibility in health care. How do you think the proposal under
consideration will accomplish that goal in the individual
marketplace and in Medicaid?
Mr. Smith. I think this proposal gives the greatest
flexibility of all to answer so many different questions.
Again, Senator McCaskill brought up an individual who had
traumatic injury. In a low-disproportionate-share hospital
State, the State may not have any way to pay for that
uncompensated care to those hospitals, so those hospitals are
eating the cost.
Under this proposal, a State could use those funds to say,
I am going to pay directly for the cost of that care for
someone who did not get insured. So the flexibility within this
block grant is really what Governors have been looking for for
a very long period of time.
The other thing to remember about the Medicaid expansion
and why some States did not take it was because they were
required to go all the way to 138 percent of poverty instead of
a State saying, we will expand Medicaid to 100 percent of
poverty because that is the poverty level, and Medicaid is for
people in poverty.
Some States, if they would have to go all the way to 138
would have taken people who were in the private sector paying
for insurance on their own, taking them out of coverage and
putting them into Medicaid.
So the Medicaid expansion issue in question is far more
complicated than, we just did not want to expand or not.
In fact, more States, if they would have had that ability,
I think would have expanded to 100 percent.
Senator Thune. Thank you, Mr. Chairman.
Senator Enzi. Thank you.
Next is Senator Enzi.
Thank you, Mr. Chairman. [Laughter.]
Senator Santorum, this has to seem like deja vu to you. You
were here when we did the Welfare Reform Act. And I am pretty
sure that the comments that you are hearing here, as I
remember, are the same kind of comments we heard about doing
that reform: that there was an assault on the poor that would
lead to rampant poverty and that there would be deaths of
thousands, if not millions over time. And how did that work
out?
Mr. Santorum. Welfare rolls, once the block grant was
deployed, welfare rolls dropped 50 percent.
I remind everybody that we gave TANF a block grant just
like we are doing here. TANF replaced a broad-based Federal
entitlement called Aid to Families with Dependent Children. It
had broad support, but was not effectively helping people
transition off welfare. And we went to a different system which
was supported by the ranking member who voted for welfare
reform, one of the 23 Democrats who voted for this bill. The
only Republican that voted against it said it did not cut
enough taxes, it did not cut enough spending. And we have,
obviously, similar complaints on this bill.
What happened was, not only did rolls go down 50 percent--I
say this all the time--but had that been the result and that
was it, then it would have been a failure. But employment among
that very group went up and went up dramatically. Poverty rates
went down and down dramatically.
And some States really took advantage of this. And you will
see this here. If this bill is successful, some States will do
a terrific job in developing really innovative solutions to
provide great quality care. Wisconsin dropped their rolls by 93
percent. And it still is an incredible program of transitioning
people from poverty and welfare to work.
But the innovation has been copied, even just in Maine
recently. Governor LePage finally reformed welfare in that
State. It took them 20 years to do it, but, again, very strong
results. So there may be a lag effect in some States, there may
be some inequity, but it creates competition, and it creates
the opportunity for States to learn from the innovation of
other States.
Senator Enzi. Thank you. I will have some written questions
for you too, because you have a wealth of knowledge on this and
have actually spent more time on this bill than a lot of other
people, not including, of course, Senator Cassidy or Senator
Graham and others. But you have given some history to back it
up.
So, Mr. Smith, what kind of delivery system reforms could a
State engage in with this block grant approach? What would they
be able to do to impact the costs that drive up premiums?
In Wyoming, by the way, we are looking at a 48-percent
increase there. We are not an expansion State. And the reason
we are not is the State did not trust the Federal Government to
come through with their promises, and so they have stayed
conservative in all of these things and in serving people.
But what could be done?
Mr. Smith. Thank you, Senator. And again, when we do talk
about insurance, at the heart of it, you are talking about
risk. And whom do you spread the risk across?
And I do want to say, I mean, we have talked about the per-
capita caps as being risks, the States being willing to accept
that risk. They are willing to accept it when they are able to
innovate and have greater ways of serving people differently
than the way they are doing it today.
But there is also a risk to the States of a strategy where
the Federal dollars will always get bigger and bigger and there
is no end to the Federal Government's contribution. That is a
risk too. And a lot of States said, we are not willing to take
that risk, because it is unsustainable for the Federal
Government as well as the States.
But the innovation that can be done, again--I mentioned we
are introducing a new type of organized care for people with
the highest costs that we can target to the individuals with
severe mental illness, to put coordinated care around them, to
take them, to some extent, off the books of the insurance
coverage, so the State manages their care directly.
There have been different concepts about sharing the risk
of reinsurance or the old high-risk pools. They were always
putting more money to the health-care plan itself to absorb
that risk. There are different ways to share that risk. And
those things can help bring down the premiums as well.
Senator Enzi. Thank you. Just a final comment, and that is
that this would not be the last bill that would be done on
health care. It might be one of the first for encouraging
changes. But I have been at those hearings that I think are
progressing in a bipartisan way, and I hope they will continue.
Senator Wyden?
Senator Wyden. I think Senator Nelson is next up, Mr.
Chairman.
Senator Enzi. Oh yes. Senator Nelson?
Senator Bennet. Mr. Chairman, I am sorry to interrupt, but
I wonder--the vote has started, and I just wondered, for
purposes of Senators, whether you could tell us what the
speaking order is for the next round.
Senator Wyden. Do you want me to do that?
Senator Enzi. Yes.
Senator Wyden. If I could, and I thank the indulgence of
acting Chairman Enzi.
So, after Senator Nelson, it would be Chairman Hatch, who
is not here, myself, Senator Grassley, Senator Stabenow,
Senator Roberts, Senator Carper, Senators Portman, Scott,
Bennet, Casey, Warner, McCaskill, of the Senators here. Okay?
And, colleagues, we do have an agreement with Chairman
Hatch that Senators get to ask all of their questions. So he is
going to vote and come back, and I will go and vote after that,
and we are just going to keep this going.
Senator Enzi. Actually, I think we will take a 15-minute
recess so everybody can vote. Well, as soon as Senator Nelson
finishes.
Senator Wyden. That is fine on our side.
Senator Enzi. Okay.
Senator Nelson. All right, and I will be quick.
Most of you know that I have been dealing with the
aftermath of a hurricane, and not only are we facing that, but
down in Puerto Rico and the Virgin Islands they are in very
tough shape. And the Medicaid program is one that is
particularly important to hurricane recovery efforts.
As it is currently structured, Medicaid can respond to
public health emergencies and natural disasters. And as the
needs go up, whether it is because people become eligible or
because they have lost their jobs or homes or that other
health-care needs grow, Federal funding goes up automatically
in response.
And so the bill in front of us is of great concern. It is
problematic that it does not provide States with sufficient
funding to respond to natural disasters like hurricanes. The
block grant provides a fixed amount of funding, and the
Medicaid per-capita cap provides a fixed amount per
beneficiary. So you can see what would happen when people need
health-care coverage and the costs are rising on a per-
beneficiary basis.
And then, what about, in the bill, the public health
expenditure exclusion from the cap? Well, of course, we have
had three hurricanes right in a matter of a few weeks, not to
mention the ongoing opioid epidemic and the presence of zika.
The bill guts the Medicaid program and, therefore, cuts
hundreds of billions of dollars of support to pregnant women,
low-income adults, and children over time.
Relaxing the per-capita cap by $5 billion in total for 50
States over a 5-year period just simply is not adequate,
especially when the decision whether to grant the exemption is
left up entirely to the Secretary.
Public health emergencies are going to continue. And that
exemption does not do anything for the greater Medicaid needs
after a natural disaster like these hurricanes.
The bill assumes that States even have enough resources on
their own to draw down on the Federal funding and that they are
not using that money to plug other holes in the disaster. And I
am telling you right now, my State is trying to get every
dollar that it can in help from the Federal Government.
Look at Hurricane Katrina back in 2005. States had to
access $2 billion, so $5 billion for 50 States over 5 years is
simply not enough.
I am really worried, and just not about my home. As I
mentioned, Puerto Rico and the Virgin Islands as well are
struggling. Their Medicaid programs are already subject to a
block grant. And it will not adjust. It would not adjust if
there were not a natural disaster. And now their needs are
huge.
But I am afraid that is what the bill in front of us wants
to accomplish, subjecting the rest of the country's Medicaid
programs to the same rigid, inflexible, flawed financing
structure.
Mr. Chairman, I know we have to go vote, so I will stop
right there.
Senator Cassidy. Can I address some of those issues,
though, Mr. Chairman?
Senator Nelson. After he gets through with the recess,
sure. Let us go vote.
Senator Enzi. Yes. We will recess for 15 minutes.
[Whereupon, the committee was recessed at 5:38 p.m.,
reconvening at 5:55 p.m.]
The Chairman. I'm glad to call the committee to order.
Now, I expect this to go two rounds, but no more. I mean,
let us face it, we are not getting anywhere, as far as I am
concerned, other than we are getting some interesting
testimony. But it is not going to solve the problems that we
have here in the Senate, and we will just have to see what
happens.
Senator Wyden has a few more questions to ask, but we will
go through one more round, and then that is going to be it.
Senator Wyden. Mr. Chairman, I am going next to Ms. Mann.
And again, these are the kind of substantive questions that you
and I agreed could be asked at this hearing.
The Chairman. Sure.
Senator Wyden. Now, let us talk, Ms. Mann, because you are
an expert about Medicaid, about flexibility. And put it in the
context of the Nation's senior citizens. That is my background.
I was director of the Oregon Gray Panthers for about 7 years. I
watched all these older people. They fought our wars, they
built our communities, they raised the families, they scrimped
and saved, but growing old in America costs a lot of money.
So today, senior citizens have a guarantee that Medicaid is
going to cover the cost of nursing home care. And this is
hugely important, because Medicaid picks up the bill for two
out of three senior citizens in nursing homes in America. That
is a guarantee for literally millions of older people.
This proposal, the Graham-Cassidy proposal, I call it
Trumpcare, the next version of Trumpcare, ends that guarantee
and effectively turns it into a guarantee in name only.
So we are not talking here about some abstraction and
bending the curve and all this hocus-pocus about State
flexibility. We are talking about the types of choices a State
is going to have to make to their Medicaid program and what it
is going to do to impact those senior citizens on an economic
tightrope, every month balancing their food against their fuel
and their fuel against their rent.
Tell us what this proposal means for the Nation's senior
citizens.
Ms. Mann. Thank you for the question, Senator Wyden. Very
few people, I think, truly understand what you just discussed,
which is the importance of the Medicaid program to our elders
in this country. There is no public support for long-term care
except in the Medicaid program. Medicare only does it in very
narrow ways. And about 21 percent of our spending in the
Medicaid program is for people 65 and older. So it is a very
important part of where the dollars in the Medicaid program go.
And as a result, when there is a cap, if there would be an
arbitrary cap on the amount of dollars that a State can spend
in its program, where a State will go, not necessarily because
it is its first choice, but because of the math, is where the
expensive services and the expensive individuals are.
And they will look to people with disabilities, and they
will look to the elderly. So they may still have the
requirement to do nursing home care, but States have expanded
some eligibility for nursing home care to make sure more people
have that option who have worked hard all their lives. And so
those optional nursing home-eligible individuals might lose
their coverage.
The other thing that States have been doing under the
flexibility in the Medicaid program is expanding to home and
community-based services and really making those more
available. But that is wholly an option in the Medicaid
program, and those are outlier costs. And when you are under a
cap, you are going to manage to the cap, as we talked about,
and cut the high-cost cases.
Senator Wyden. I appreciate your saying that, because I
want people to walk out of here and understand that the
Nation's senior citizens who have counted on a guarantee, under
this program they effectively are seeing that guarantee
hollowed out. And I very much appreciate your testimony.
I have one other question, again on the State flexibility
issue. And I think you know, I feel strongly about State
flexibility. It is the flexibility to do better, not to do
worse.
And what I would like to have is your opinion about
whether, as a result of this particular piece of legislation,
any State is going to actually do better overall. And I want to
underline ``better overall,'' because it seems to me that what
this bill does is, it gets people coming and going. It
basically is about, nationwide, repealing the Affordable Care
Act, but it is also about, State by State, repealing the
Affordable Care Act.
So if you would, tell me whether, in your opinion, as a
result of this legislation, any State is actually going to do
better overall or if one State will or two States. I would like
to hear your thoughts on it.
Ms. Mann. I think overall, the answer is absolutely not,
they will not do better.
Senator Wyden. Not a single State overall will do better?
Ms. Mann. Well, do better is--I am not sure of the
question. I think overall, when you have a cap and you are
going to manage to a cap as opposed to thinking about how to do
the kinds of things that Mr. Smith talked about that States can
do now under flexibility--have a better delivery system,
integrate behavioral health, physical health, do accountable
care organizations--those are flexible things that States can
do to improve care and to lower costs. And States can do that
now.
But what will happen under a cap is that you have to manage
so that you never go a dollar over that cap, or if you do, you
will owe the Federal Government more dollars. And so you have
to focus on quick, immediate steps to bring down your costs so
that you are never at risk or you are trying to at least not be
liable for that extra payment back to the Federal Government.
Senator Wyden. I will hold the record open for your views
on that because that, to me, seems like a threshold question.
You know, we have been hearing all afternoon about State
flexibility that is some magical elixir that, you know, if we
have it in the
Graham-Cassidy version, then everything is going to be hunky-
dory. You have pointed out that that is not the case because of
the way the cap option----
Ms. Mann. And it is the Medicaid directors themselves
around the country, not in the red States, not in the blue
States, but around the country who have said that when you have
flexibility without funding, that is not flexibility at all, it
is only flexibility to cut.
Senator Wyden. I am going to quit while I am ahead. Thanks.
Thank you, Mr. Chairman.
The Chairman. Well, thank you.
Let me just say this.
Mr. Santorum and Mr. Smith, can you respond to Senator
Wyden's question?
Mr. Santorum. Let me just say about funding, the idea that
some States are not going to do better under the Graham-Cassidy
bill is just fallacious. Clearly, the non-expansion States get
an enormous amount of money coming into their coffers to use
for, quote, the ``Medicaid expansion'' or basically the
individual market.
In addition, they can use up to 20 percent of that money to
support the per-capita-granted Medicaid program. So they have
increased flexibility in addition to more money coming in for
this population that right now they are not drawing down any
kind of Medicaid expansion dollars for, so they can draw down
these block-granted dollars.
Again, in this second block grant, this replacement of the
Affordable Care Act that is in Graham-Cassidy, only 13 States
under this formula get less money than they are projected to
get under current law. So the idea that all of these States are
being slashed or there is this great redistribution of wealth
between States that are, quote, ``blue States and red States''
is simply just not the case.
The phase-in of this program is deliberate. It is slow. It
takes 10 years. There is a lot of flexibility that comes with
this extra money.
I mean, yes, you have flexibility in, well, as I said, all
but 13 States, so that would be--well, that includes the
District of Columbia, so in 38 States you are talking about
more money and more flexibility to be able to deal with this
population that was the target of the ACA.
So I do not know if Dennis wants to add the part about how
this interacts with Medicaid, but I think that interaction is
actually positive too.
Mr. Smith. Thank you, Mr. Chairman.
The Chairman. Sure. Give us your view on that, and then we
are going to turn to Ms. Mann. We will have Ms. Mann sum it up.
Or if you would like to, let us go first to you, Ms. Mann,
and you can make any comments you want. And then we will come
back to you, Mr. Smith.
Ms. Mann. So I am not sure what numbers Senator Santorum is
referring to. I think it is numbers that actually add in State
dollars and States' own dollars to what they would get under
the block grant. You cannot have everybody getting more money
under a block grant that at the end of the day redistributes
the dollars very radically from high-cost and high-coverage
States to those that are not doing it.
There are no winners under this bill. You have every State
putting the bulk of their Medicaid program, the vast majority
of their Medicaid program--the elderly, the disabled, the
children, the pregnant women--under a cap, so that when cancer
treatments come out, if they are more expensive, the State will
not be able to afford those costs or at least not without
cutting something else. If there is the next hurricane, they
cannot afford to address that emergency unless they cut
something else. That is not how the financing in the Medicaid
program works now.
And it is so important to understand the basic structural
change to financing for the vast majority of Medicaid
beneficiaries.
The Chairman. Okay.
Mr. Smith?
Mr. Smith. Thank you, Mr. Chairman.
Again, obviously, we believe that Arkansas will be better
off, or I would not be here today. And a number of other
Governors feel the same way. So we believe that there is great
value in this, in terms of a level of funding that is
sustainable for both the States and the Federal Government.
These dollars continue to grow over time.
As I mentioned previously, medical CPI plus one is higher
on a per-capita basis for elderly and disabled enrollees; it is
higher than what CBO has in their baseline. So we believe that
this is sustainable.
We also believe that, while we have had progress--and both
Ms. Mann and I have been part of that at CMS as we held the
same job of, again, encouraging States to adopt greater and
greater services in the home rather than in an institutional
place of care.
But I will also say, States have a long, long ways to go
with what they can do. I think we just recently hit the 50-
percent mark for long-term services and supports, with barely
over 50 percent of the Medicaid dollars for LTSS going to home
and community-based service settings rather than to an
institutional case setting.
So that tells me we still have a long ways to go to be able
to serve people in their own homes, in their own settings,
where they want to be. And that will, again, help to lower the
cost curve, as we know that those are more cost-effective over
time.
The Chairman. Senator Carper, have you had your time?
Senator Carper. Senator Casey has asked me to yield to him.
He has another engagement.
So I am happy to yield to him and maybe slip in later.
The Chairman. That will be fine.
Senator Casey. I want to thank Senator Carper for that
courtesy.
Just for the record, there was a reference earlier, or
several references, to the Governors. That letter that they
wrote, those 10 Governors, bipartisan, in the first paragraph
they suggested not considering the bill--that is significant--
but then they ended with what I think is a pretty good
summation of what we should all be doing. And I think we
started this in the HELP Committee. Here is the Governors'
second-to-last paragraph, quote: ``We ask you to support
bipartisan efforts to bring stability and affordability to our
insurance markets. Legislation should receive consideration
under regular order, including hearings in the health
committees and input from appropriate health-related parties.
Improvements to our health insurance markets should control
costs, stabilize the market, and positively impact the coverage
and care of millions of Americans, including many who are
dealing with mental illness, chronic health problems, and drug
addiction.''
I think that is a pretty good summary of what we should all
be doing. And I hope we can get back to that. But part of the
predicate for that is, this bill does not pass, so we have some
work to do this week.
Ms. Mann, I promised that I would come back to you with a
question that I posed to Secretary Miller with regard to what
happens to Medicaid expansion. I asked her about the impact on
Pennsylvania. In your judgment, based upon your experience--and
I want to refer again to your time as both Deputy Administrator
and Director of the Center for Medicaid and CHIP Services for
CMS--what is your sense of what that means for the country,
just the winding down of Medicaid expansion?
Ms. Mann. Thank you, Senator. Well, first of all, it is not
even winding down. January 1, 2020 it simply goes away.
Senator Casey. Right.
Ms. Mann. And some 11 million people who are covered under
the Medicaid expansion, they simply will not have--the States
will not have the legal authority or any ability to get Federal
matching dollars in order to continue to cover them.
The expansion has been enormously valuable in those States
that have done it. Those are the States that have lowered their
uninsured rates to record lows. And while the Nation as a whole
has lowered its uninsurance rates, particularly it has happened
in expansion States.
But more than that, people have been getting care. Governor
Snyder keeps a great dashboard in Michigan of how many people
got mammograms and how many people got colonoscopies and how
many people got preventive care.
The Louisiana dashboard for their expansion, they got
433,000 people covered under their Medicaid expansion, and they
can tell you how many people got preventive testing and then
were found to have illnesses and then got the treatment for
those illnesses. It is real people, real services.
But in addition, it has lowered uncompensated care costs.
It has really helped hospitals stabilize their funding. You saw
the map before about rural hospitals being most affected in
non-expansion States.
And it has also helped State budgets, as expenditures that
a State might otherwise be needing to make now can be covered
through the Medicaid expansion.
All of that goes away if the expansion goes away.
Senator Casey. And one of the points that you make, which I
think is of paramount concern to me, is just the guarantee of
Medicaid. In other words, you could have a family that has--and
we saw this in some of the reaction of folks around the country
the last couple of months--families with high incomes, good
health care, but who still need Medicaid because their son or
daughter has a profound disability of one kind or another. So
not only--I mean, we have all kinds of families benefitting
from that guarantee.
The last thing I will say is, on page 3 of your testimony
you mention the taking away of that guarantee. And then you go
on to talk about the other side of Medicaid, meaning the
original Medicaid program itself.
You say the consequences of this major change in financing
falls solely on those enrolled in the traditional Medicaid
program, newborns and other children, very low-income parents,
pregnant women, low-income seniors, and people with
disabilities.
And, if you want to add anything to that in 15 seconds----
Ms. Mann. Well, and that is the irony of this, because a
lot of the criticism about the expansion, even though there are
people at 10 percent of poverty, 15 percent of poverty, 60
percent of poverty, is that, oh, the resources should go to the
traditional Medicaid program. And yet, this bill would cut
those resources and impose an arbitrary cap. So those pregnant
women and those children and those elderly and disabled
individuals will not have that guarantee for funding, and the
States will not be guaranteed that they will be able to afford
the kind of treatment that those individuals need.
Senator Casey. Thank you.
Thank you, Mr. Chairman.
The Chairman. Senator Stabenow?
Senator Stabenow. Thank you, Mr. Chairman.
First, I would like to submit for the record some of the
emails that I have gotten just in the last several days from
folks who are opposing this bill.
The Chairman. Without objection. Without objection, they
will be included in the record.
Senator Stabenow. So I will leave this with you. Thank you
very much.
[The emails can be viewed on the committee's website.]
Senator Stabenow. Mr. Chairman, I also want to emphasize
again that I wish we were having a markup on the Children's
Health Insurance Program, which you and our ranking member and
myself and others have introduced, a bipartisan bill that is
very important, 9 million children, and we will see CHIP ending
at the end of this week----
The Chairman. That is right.
Senator Stabenow [continuing]. Along with community health
center funding. Senator Blunt and I have 70 members of the
Senate on a letter indicating we want to make sure that
community health center funding is done by the end of this week
as well.
And we have a very important effort that is going on right
now in the HELP Committee, a bipartisan effort with Senator
Lamar Alexander, Senator Patty Murray. I want to thank you, Ms.
Miller, for being a part of those discussions.
And that is what we should be doing: a bill that rolls all
that in together. And frankly, what we are hearing about today
and over and over again in terms of the Affordable Care Act is
really the part of the Affordable Care Act that is the
individual marketplace, where less than 10 percent of the
people are--in fact it is 6 percent in Michigan--who have
gotten increased coverage through the individual markets.
And in fact, we have situations where copays and premiums
are too high. No question about that.
But it is being used as a smokescreen, in my opinion, to
hide what is really going on here behind the curtain, which is
a gutting of Medicaid. Seniors in nursing homes--three out of
five seniors in Michigan are in nursing homes--and Alzheimer's
patients get their nursing home care through Medicaid, and
children, and families.
And now we have a CBO score that literally just came out
that tells us the facts. And they are, in addition to seeing
Medicaid coverage going down and coverage in the insurance
system and so on going down, that just in Medicaid in the 10
years, 2017 to 2026, there would be a cut of $1 trillion.
Now, I have been using numbers that were not $1 trillion,
but now it is $1 trillion in coverage cuts to seniors in
nursing homes and children and families. And that is really
what the goal is, I believe, with all due respect. I mean, that
is what folks are going for, because we can fix the individual
market without gutting Medicaid and taking away individual
coverage for people.
I want to talk about one of the areas of individual
coverage, and that is mental health, something I care deeply
about.
I know, Senator Cassidy, you and I have talked about our
interests in community-based services for mental illness and
opioid addiction. And in the first bill you introduced, I know,
the Patient Freedom Act, you actually included protections for
mental health and substance abuse, even though you were
creating the possibility of eliminating the essential health
benefits.
But in this new bill, that is not the case. There is no
protection under essential benefits for mental health.
Senator Cassidy. Can I respond to that, please?
Senator Stabenow. Yes, you may.
Senator Cassidy. First, let me say one thing about the $1
trillion cut to Medicaid. It is repurposed into the flexible
block grant. The money is still there, it is just not called
Medicaid.
As regards mental health parity, yes, mental health parity
is still there under this law. And I do not have it in front of
me----
Senator Stabenow. I am going to stop you only because I
agree, mental health parity is. In fact, I was proud to author
that provision in the bill in this committee.
Senator Cassidy. No, no, I am talking about my bill.
Senator Stabenow. No, I know. I understand it is still
there. That is not what I am talking about. So what you are
saying--what we said with mental health parity is, that if you
offer insurance, you have to offer this same kind of insurance
for mental health. But because it is not included as an
essential benefit, you no longer have to offer it.
Senator Cassidy. That is not true. What it says is, any law
before 2009 still applies.
Senator Stabenow. Okay.
Senator Cassidy. So if they offer insurance for physical
health, they have to offer matching care for mental health.
Senator Stabenow. Okay, well, let me turn now to get----
Senator Cassidy. That is in the bill.
Senator Stabenow. Essential benefits, offering that, what
is in a package is different than mental health parity. I would
agree with you that mental health provisions are in there.
But, Ms. Miller, under this bill, insurers can end coverage
of mental health and substance abuse services just like any
other essential health benefit. Is that correct?
Ms. Miller. That is correct.
Senator Stabenow. Okay. And so it is not the same thing as
parity, because you do not have to offer it in insurance plans.
Also, Ms. Mann and Ms. Miller, what is a person in a
situation supposed to do who can no longer get the treatment
that they need for substance abuse, opioid addiction, or mental
health services? And what would it cost for someone who is in
that situation?
The Chairman. Senator, your time is up.
Senator Stabenow. I would like them to answer, please.
The Chairman. Well, let us live within the 5-minute rule.
Senator Stabenow. If they could just answer the question,
Mr. Chairman.
The Chairman. We are all getting tired of this.
Senator Stabenow. Okay. Mr. Chairman, if they could just
have a chance to answer the question of what is a person in
that situation who no longer has mental health coverage
supposed to do.
The Chairman. Let her answer the question.
Ms. Miller. I think that is a really good question. I think
one of the things I worry about is, under Medicaid expansion in
Pennsylvania and our individual market, the impacted markets
here with this proposal, we have had 175,000 people in
Pennsylvania who have accessed substance abuse treatment. And
moving to this block grant and this reduced funding, I worry
about whether or not those individuals who are getting that
treatment will in the future be able to continue that
treatment.
Senator Stabenow. Thank you.
The Chairman. Yes. The one thing that bothers me is, nobody
asks, especially on the Democrat side, where is the money
coming from? How do we pay for this? Who is going to get socked
for all this, regardless?
Now, we all want to help in every way we possibly can, but
there is a limit to everything.
Senator Portman?
Senator Portman. Thank you, Mr. Chairman.
I am glad to be back. I was here for a few hours earlier.
And I support hearings, and I think we should have had more
hearings with regard to this particular bill and, for that
matter, health care in general. And so I would agree with what
was said earlier about the need for more regular order, because
we are actually beginning to get some of the facts out.
And one of the facts, as I understand it, is that--as an
example with regard to expanded Medicaid, which we did in Ohio,
which has been very important on substance abuse treatment--
that money continues to flow.
And so the notion that you are worried about what is going
to happen in Pennsylvania, Ms. Miller, I would hope that you
and your Governor and others would continue to provide that
funding for mental health and for substance abuse treatment,
because it is going to be needed.
And you know, the one thing that also has not gotten talked
about here today--and look, I am still undecided on this bill
because of the numbers. I am looking at the numbers, and they
have changed, let us face it, even over the weekend, where Dr.
Cassidy was helpful to us in Ohio and I think you in
Pennsylvania and other States in allowing us to make some
adjustments on the formula.
But certainly in my State, and I assume in all of the
States, this 10-percent match is really onerous. I mean, it is
really onerous to the point that in Ohio, you know, our
legislature is not interested in providing the 10-percent
match. Moving just from 5 to 10, I am talking about. And in
this legislation, you do not have to put up the match in order
to get the money.
So I mean, I am looking at the HHS numbers here, and, Dr.
Cassidy, maybe I have this wrong, but current law would be, in
year 2026, about $49 billion. Under this, it is about 9 percent
more--these are HHS and OMB numbers--up to $53.7 billion if you
include the State match not having to be paid to get that
money. In other words, you would be able to get it without
putting up a match, so that is about a 9-percent increase.
Other numbers I have seen show that it would be about a 3-
percent reduction over that 10-year period or, I guess, 10
years from now, a 6-year period during the bill.
If I were a Governor and you told me, you get flexibility
to be able to cover these low-income folks in the way you want
to, the most effective way--and by the way, 40 percent of our
providers in Ohio are not accepting Medicaid. I do not know if
that is true in your States. But Medicaid is incredibly
important. It is absolutely essential to have it.
But let's face it, it needs reform for a lot of reasons.
One is, the reimbursement is such that many providers do not
want to take it, and they are not required to. And so Medicaid
recipients do not have the choices that many of us around this
dais have.
But that flexibility, I think, is what I hope--regardless
of what happens with regard to this hearing and this week and
any vote we have, we ought to have an honest conversation about
that. And I think Democrats and Republicans alike believe there
ought to be more flexibility, I hope. Because some of the
examples that were used earlier of some States that have been
innovative and some States that want to be a lot more
innovative to get people into private plans who are in Medicaid
right now and to cover them with better health care where they
have more options, they can go to more specialists and more
doctors, is that not a good thing?
So I guess I would ask someone, Dr. Cassidy, I guess you
are the best, am I right about the numbers, that actually Ohio
under this provision would get more funding based on the HHS
and OMB analysis? And why is that different than where the CMS
actuaries were?
Senator Cassidy. Yes. So the CMS actuaries had the first
bill, and that is when we learned over the weekend that the
inflation rates are just incredible that are projected for the
individual market.
So we reworked the bill. We do not get to equity as soon as
we would like. On the other hand, we keep there from being a
big drain from States which have already expanded.
And you are right. Ms. Miller, in all due respect, seems
not to think that Governors will have any imagination on how
they will use these dollars.
But obviously, Mr. Smith comes up with all these
imaginative ways. And your Governor has been imaginative. And
Maine has been imaginative.
By waiving the match--in your State it is $49 billion under
current law, it is $47.54 billion under our proposal, and then
you can waive the match to the tune of $6.2 billion.
Senator Portman. And that is how you get to 53.7.
Senator Cassidy. Fifty-three-point-seven.
Senator Portman. Yes.
Mr. Santorum. If I could add to that.
Senator Portman. But why is that different? The CMS
actuaries were lower, and why was that?
Senator Cassidy. Well, they had done the previous bill.
Mr. Santorum. Right. The change we made in adapting this
bill was, number one, going from a phase-in of the formula over
a 6-year period of time to a 10-year period. So the States that
are expansion States keep their levels higher longer, and that
is one reason. And the second is, we put a cap on the growth of
the non-
expansion States.
Senator Portman. Okay. Let me ask another question about
the formula. I was pleased to see over the weekend, and we
talked a lot about this--I was concerned about Ohio. We removed
the CHIP AV formula that I think would have hurt Ohio by
resulting in less funding. That is out of there now?
Senator Cassidy. Yes.
Senator Portman. That is one reason I think Ohio and other
expansion States do better now.
Another one that concerns me still is not to include those
between zero and 50 percent of the Federal poverty line. Why do
we only include 50 percent in your bill up to 138 percent? Why
not include those between zero and 50 percent in the formula?
Senator Cassidy. That is just the means to distribute the
dollars, the denominator, if you will.
On the other hand, the money can be spent as long as the
focus is on the lower income and the working income, and that
is per CHIP regulations. Again, this goes through CHIP with
those guardrails.
But on the other hand, that is just the means to
distribute. We had to pick a number, and that is kind of the
CHIP focus.
Senator Portman. Well, it is a means to distribute, but in
Ohio we cover those people, so----
Senator Cassidy. And you still can. You would just use the
dollars. Again, it does not prejudice how you spend the money.
Senator Portman. I understand.
The Chairman. Senator, your time is up.
Senator Portman. It helps us to have his formula.
Thank you, Mr. Chairman.
The Chairman. Senator Bennet?
Senator Bennet. Thank you, Mr. Chairman.
And I think we have heard a lot today about how you can cut
all this money and continue to insure people. We now know from
the CBO with their truncated score, a score that they should be
able to do over the next weeks and months, that millions of
people will lose their insurance if we pass this bill.
Now, I understand that somebody could have a principled
position. Senator Santorum may have had this position in the
past, I do not know, a principled position to say the Federal
Government should not be in the business of health care. I have
heard people say that for 8 years. And I have heard others, my
friend--and he is my friend--from Ohio say that Medicaid needs
reform.
The problem that we are facing as a country, not just in
these States, and I will--Mr. Chairman, may I insert for the
record all the money Colorado is losing as a result of this
legislation?
The Chairman. Without objection, we will put that in the
record.
[The information appears in the appendix on p. 91.]
Senator Bennet. Thank you. And I would say it has been
amazing to watch supporters of this bill waving a flag around
or a map around of who the winners and the losers are.
Senator Paul said it very well, that this is a transfer
from Democratic States to Republican States. It is obvious what
is going on here. And in a world where the cornhusker kickback,
so called, set off so many people, they should be appalled by
that kind of discussion here.
But in any case, the problem that we face as a country is
that I have a bunch of people in Colorado who make too much
money to be on Medicaid, but who cannot afford private
insurance. That is a huge problem in America.
And it is a huge problem that there are a bunch of people
on Medicaid who, if they lose their Medicaid, will have an even
harder time buying insurance than middle-class people who
cannot afford it because we have not created the kind of
transparency around health care that other countries have, and
we have not created the kind of incentive structure that would
drive down costs, which is really what we need to do if we are
concerned about preserving the entitlement and doing something
useful for our budget.
This throws a bunch of people off Medicaid with absolutely
no suggestion about how they will be covered, which means that
we will once again have uninsured people showing up in
emergency rooms all over the country.
In Colorado, Mr. Chairman, a lot of rural hospitals had 14
percent bad debt--they called it uncompensated care--before the
Affordable Care Act was passed. That number has dropped to 2
percent. That represents a huge savings that, if those folks
are no longer on Medicaid, will be wiped out, and we will be
once again chasing our tail around this place.
I appreciate my colleagues' commitment to federalism, but I
suspect that part of the reason why this has become an
attractive vehicle is not just that it is the last one
standing, but that it appeases my colleagues on the other side,
who have voted 60 times in the House to repeal Obamacare, but
in 7 years were unable to forge a consensus among themselves
about what a theory on improving American health care should
be.
And so what they have done is left it to the States. An
admirable thing to do from a federalism perspective; I am just
suggesting that there might have been other reasons.
But in doing it the way they have done it, Mr. Chairman--
and, Ms. Miller, I am coming to you. We talked, you and I
talked about the instability in the individual market as a
result of this legislation. Now let us talk about the
instability over the next 2 years as every State in America is
going to be forced at exactly the same moment to try to create
an entirely new health-care system in a 24-month period without
knowing what the funding levels are going to be for months and
months and months, with part-time legislators, full-time
legislators. What does that all look like in America?
And who are we, by the way, to set that agenda for our 50
States? It certainly will be a great boon to health-care
consultants in America, but I am not sure it is going to be
great for the American people.
Ms. Miller? Thank you.
Ms. Miller. Well, I think one of the problems is, I do not
know that it will be a big boon to the health-care consultants,
because States do not have any funding like we did when the ACA
passed to hire consultants to help us figure out how to do
this.
Senator Bennet. So is there no money? There is no money in
this program to set up the program?
Ms. Miller. To help us figure out what to do, no. And I
think that is one of the fundamental issues.
But I think it is also that, in a 2-year period, I have no
idea how we would figure out what this new system is going to
look like. Getting legislation passed in Pennsylvania is not an
easy thing to do.
Senator Bennet. Really? It is so easy here, I do not know
why it would be hard there. [Laughter.]
Ms. Miller. And we do have a full-time legislature, but we
would have to bring all of our stakeholders together, figure
out what this new system could look like, and put all the
pieces in place to make it happen.
With the ACA, States had 4 years and they knew what they
were aiming for. They knew that if they wanted to create a
State-based exchange, that is what the new system would look
like.
Here, we do not know what this new system would look like.
And 2 years--I am not sure if we could do it in 5, but in 2
years I do not know how we would possibly do that. And I think
in the meantime we have individual markets that are going to be
significantly destabilized because this bill will throw the
individual market into chaos.
Senator Bennet. Thank you, Mr. Chairman.
The Chairman. Thank you.
Senator Cassidy. Mr. Chairman, could I correct a question
of fact?
The Chairman. Sure.
Senator Cassidy. There is a $2-billion implementation fund
included in the bill, number one. Number two, the CBO score,
JCT score which you quote, does say that States could elect to
continue their current Medicaid programs. So I just wanted to
correct that.
The Chairman. I have to give you credit. You have been very
effective here in front of this committee, and you are a
doctor.
Senator Bennet. Well, Mr. Chairman, I appreciate the fact
that we are now relying on a CBO score which should have come
months ago or weeks ago.
The Chairman. Well, I agree with you.
Senator Bennet. And I know you would. But it says that
millions of people will lose their health insurance as a result
of this terrible piece of legislation.
The Chairman. Senator Carper?
Senator Carper. Mr. Chairman, I ask unanimous consent that
these messages from citizens of Delaware be admitted for the
record, please.
The Chairman. Without objection, they will be admitted.
[The messages can be viewed on the committee's website.]
Senator Carper. Mark Twain once said, ``It ain't so much
what people do not know that bothers me, it's what they know
for sure that just ain't so.''
I am going to ask, starting with Ms. Miller, Ms. Mann, and
Mr. Woodruff, just to think back on some things you heard from
us, from this panel, it could have been the other witnesses,
but some things you heard that just ain't so.
Do you want to lead it off, Ms. Miller? Be brief. This is
not to impugn anybody's integrity or honesty, but what have you
heard that just ain't so?
Ms. Miller. I think the difficulty I have with a lot of the
discussion is that we are talking about, in this proposal,
making drastic cuts in Medicaid. I mean, that is what we are
talking about, but we are doing it under the guise of
Obamacare's failing.
And again, when we talk about Obamacare failing, what we
are talking about is the problems with stabilizing the
individual market. And we have all agreed there are problems
with the individual market, and we need to stabilize that
market.
Senator Carper. And a lot of them are self-inflicted
wounds, if you do not mind my saying so. Yes, there are things
that we could do. Go ahead, go ahead.
Ms. Miller. There absolutely are. I think the very people
who want to get rid of Obamacare were the very people who have
helped it struggle in some cases. And I think that
fundamentally there is nothing in this bill that will stabilize
the individual market. It will do just the opposite.
Senator Carper. Good point.
Ms. Miller. But we also just need to be clear about what we
are doing. We are making major, major reductions in the
Medicaid program.
Senator Carper. Thanks.
Ms. Mann, what have you heard that just ain't so?
Ms. Mann. I have a long list, but in the interest of time,
let me hit on three points.
Senator Carper. Really quickly.
Ms. Mann. One is, there has been a lot of discussion about
the 10-percent match. Of course, it was not fully a 10-percent
match for a while, but it was a 10-percent match that has kept
some States from expanding Medicaid.
For the most part, it was, besides the politics, the
uncertainty about whether the 90 percent would still be there
that kept a lot of States from jumping into expansion. And look
at the uncertainties of the funding in this new bill. You have
zero funding in 2027. You have to imagine something will come
about at that point. That uncertainty makes the uncertainty
about Medicaid expansion funding pale in comparison.
Second, again, concern about States meeting their State
match. On the traditional Medicaid side--the much bigger
expenditure for States rather than the expansion--this bill
would reduce States' flexibility to rely on provider taxes, a
very prominent way that States have used to be able to finance
their Medicaid programs. It would reduce their reliance on that
considerably.
And then finally, it is this myth that we can have a capped
amount of money and, if you are concerned about this problem,
we can fix it; if you are concerned about that problem, we can
fix it.
As I understand from CBO, their analysis says, sure, every
State could replace their Medicaid expansion with these block
grant dollars and there would be not a penny left then to do
the insurance reforms and the stabilization that we also think
are incredibly important.
Senator Carper. Thank you.
Mr. Woodruff, what have you heard that is just not so?
Mr. Woodruff. Just really quickly, the absurdity of the
allegation that you can take hundreds of billions of dollars
out of Medicaid and continue to insure the same number of
people who are being insured now.
And secondly, that we can expect the States to create out
of whole cloth a new insurance system in 2 years when they had
such a difficult time doing a much easier system in 4 years
under the Affordable Care Act.
Senator Carper. All right. Let me just note for the record,
I have never been a doctor. I have been a Naval flight officer,
studied some economics, got an M.B.A., State Treasurer,
Governor, chairman of the National Governors Association, lead
Governor on welfare reform. And I have thought a lot about
these issues.
One of the reasons why welfare reform worked is because we
launched right in the middle of one of the greatest economic
expansions in the history of our country. Unemployment went
down; revenues went up. We were able to make sure that people
were better off getting off of welfare and going to work.
What we have coming at us right now is a tsunami. It
includes a combination of things: a baby boomer generation, a
tidal wave that just keeps on coming.
It used to be when I was State Treasurer, most of the money
we spent on Medicaid was for moms with children in poverty.
Today, it ain't so. It is, like, two-thirds of the money we
spend on Medicaid is for people--our parents, our grandparents,
our aunts, and our uncles--a lot of whom have dementia and are
in poverty.
Two million of the folks who use Medicaid are veterans. I
am a veteran. Two million are veterans, and we have this tidal
wave of drug abuse that is sweeping across our country.
And before we go ahead and pull the rug out from the
States--before we go ahead and pull the rug out from the
States--we need to hit the pause button, and why do we not just
set it aside and say, let us maybe stop working just as
Democrats or just as Republicans; maybe we should try this
together.
An old African proverb--I will close with this, Mr.
Chairman--an old African proverb goes something like this. If
you want to travel fast, go alone. If you want to travel far,
go together. This is an issue that begs for us to travel
together on.
Thank you.
The Chairman. Senator Cantwell?
Senator Cantwell. Thank you, Mr. Chairman.
I want to go back to my first round, because now that we
have the CBO score, which is pretty illuminating--well, I would
say it is pretty detailed in the bill's effect on Medicaid. On
page 7, I note it says, quote, ``In general, States would not
have substantially additional flexibility under the per-capita
cap.'' So a few States would probably obtain additional
flexibility.
And then it goes on to say, quote, ``However, because
funding under the program would grow over time at the rate of
CPIU, CBO anticipates that it would be attractive mainly to the
few States that expect to decline in population and would have
little effect on enrollment in Medicaid.'' That is who would be
attracted to it.
It would not be attractive to States that are experiencing
population growth, as they would not be adjusted for that
growth.
So, okay, I do not know if this is the people designing
this who did not want to expand, who did not think that it is
increasing affordability, because it is, that it is increasing
access to care, that it is bringing people up, and now they are
proposing something that is really about just being attractive
if you really just think you are going to have lower
populations and not cover people.
I am interested, though, because there is a commonality,
Mr. Smith, between you and Ms. Miller, in that you both support
Community First Choice programs in the context of delivering
access to care through more affordable rates. And the 85
percent of home and community-based care versus 15 percent
nursing home care, that is what we have been able to achieve in
our State.
The Graham-Cassidy bill further cuts that incentive there
to get States to do that. Wouldn't that be a huge cost saver? I
am talking in the tens of billions, if not even in the hundreds
of billions of dollars, if we could get States to achieve a
better balance on
community-based care versus nursing home care. Isn't that real
money?
Ms. Miller. I think it would be, and that is one of the
innovations that States can do today under existing waivers.
Senator Cantwell. Well, Graham-Cassidy actually rolls that
back. So it disincents it. I think we should put pedal to the
metal and incent it even more because, frankly, about 10 or 15
States have taken us up on it. And I think that this is real
savings. Plus, who doesn't want to get community health at
home?
Ms. Mann, I see you nodding your head.
This is the right strategy. So our colleagues who say that
there is no savings in changes that we can make in Medicaid,
here is a win-win-win. People would love to stay at home and
age, would love to have care delivered there instead, and,
guess what, it is way cheaper than nursing home care.
And if you are going to accept a population of people who
are reaching retirement and demanding more of those services,
then you want to implement something like this and continue to
incent it. So definitely you do not want to--yes, Mr. Smith?
Mr. Smith. Senator, if I may clarify, because I think we
were talking about two different programs: the Money Follows
the Person, which we created in 2005, and then the Community
First Choice provision, which offered an enhanced match.
But with that enhanced match, States were required to be
Statewide. So you could not have any waiting list whatsoever.
In Medicaid waivers--and we have had 30 years of experience
now in home and community-based waivers--States were allowed to
have a waiting list. Not under the Community First Choice,
however.
So there are a number of States, including Arkansas, that
could not afford to go Statewide, even with that 6 percentage
point enhanced match rate.
So again, part of this is, there are both incentives and
barriers to be able to do some of the things that were
available then.
Senator Cantwell. Yes, I appreciate that.
Senator Cassidy. And if I may say, on page 100, we ensure
access to home and community-based services. That is page 100.
Senator Cantwell. You know, I think the issue for us in the
Pacific Northwest is, we are just a little tired of the tail
wagging the dog when it comes to these issues. We deliver
better care at lower costs. Okay? We deliver less expensive
care, probably $2,000 to $3,000 less per Medicare beneficiary,
than Louisiana, and we deliver better care. Okay?
So we know what innovation is, and we want to run towards
it. Some people want to walk, and we get that; we want to run
towards it. These are the real savings.
So if you cut the innovation out in Graham-Cassidy that
already exists for State flexibility, then you are going to put
us even further behind in achieving some of these savings that
are really on the delivery system side of the case that we have
to get to.
And so that is my point, Mr. Chairman. I see my time is
expired.
But I just hope that people will hear what Ms. Miller had
said in the first round, and that is, these are the big things
that are going to help save us and drive down cost.
The Chairman. Thank you, Senator.
Senator Cantwell. Thank you, Mr. Chairman.
The Chairman. Thank you.
Senator Brown?
Senator Brown. Thank you, Mr. Chairman.
Let me tell you about the young man in the blue shirt on
the poster board behind me. This is Dr. Bignall, whom I met at
Cincinnati Children's Hospital. This is Kaden. Kaden is 3 years
old. This is Kaden's older brother and Kaden's grandmother.
He looks like any 3-year-old with that mischievous smile on
his face. He has already been through more in his 3 years on
this earth than most of us will go through in our lives. He was
born with failing kidneys due to a condition called obstructive
uropathy. But thanks to his Medicaid coverage, his doctors at
Cincinnati Children's were able to make sure that he was able
to begin life-
sustaining dialysis treatment when he was 2 weeks old.
Two years later, Medicaid covered the kidney transplant to
save Kaden's life. Now, like hundreds of thousands of other
children in the State of Ohio, Kaden relies on Medicaid and the
CHIP program, which we have not reauthorized--we have not; this
committee frankly has failed to do its job. It expires
September 30th. Because of CHIP and Medicaid, he is doing okay.
They have given him the chance to grow and learn and play and
thrive.
Now, Senator Cassidy, in light of your response on
questions, your answer that, because of the flexibility,
Medicaid can take care of Kaden and children's hospitals, and
Medicaid, because of the flexibility given to Governors, can
take care of opioid treatment, and because of its flexibility
Medicaid can take care of seniors in nursing homes, and because
of its flexibility Medicaid can do all kinds of things, could
you assure us today that States will have the capacity to fully
cover high-cost patients like Kaden? ``Yes'' or ``no''?
Senator Cassidy. Absolutely.
Senator Brown. Okay.
Ms. Miller, Ms. Mann, comment on that.
Ms. Mann. Every aspect of the financing for coverage that
we are talking about, whether it is in traditional Medicaid or
whether it is through the new block grant, will have a capped
amount of Federal dollars. There will be a finite amount. And
unless a State is able and willing to put up its additional
dollars, there is no guarantee that high-cost, high-needs
individuals will continue to see the care that they need.
Senator Cassidy. May I correct Ms. Mann for one thing?
Disabled children are specifically carved out of the cap. They
can receive as much as they currently do.
And I can also point out, when Mr. Smith points out there
are capitation payments to managed-care companies, these people
you describe are within those capitated amounts.
Senator Brown. Okay. Ms. Miller, before you respond
specifically to his comments, which I think have been
fundamentally in error through much of this hearing, we talked
earlier about the competition in Lansing and Harrisburg and
Jeff City and in every other capital, in Indianapolis--how do
you fund opioid treatment at the same time? The competition in
State capitals from all those advocates, children's advocates,
opioid treatment advocates, senior advocates, hospital
advocates, how does this play out? How in fact is Kaden
protected?
Ms. Miller. That is my concern. I am looking at the CBO
analysis that said in 2020 both expansion and non-expansion
States would receive about 10 percent less funding under block
grants than the amount they would receive otherwise through
Medicaid expansion and individual market subsidies.
But by 2026--and this impacts Pennsylvania--expansion
States, like Pennsylvania, would receive about 30 percent less
funding than we would otherwise receive through Medicaid
expansion and individual market subsidies. And non-expansion
States would receive about 30 percent more. So I do think we
are looking at huge transfers of funding from expansion States
to non-expansion States. And in Harrisburg, that is going to be
a big problem.
Senator Brown. So in Ohio, we had a Republican Governor, as
you know, who expanded Medicaid. Even in Ohio, only 24 percent
of children with intellectual or developmental disabilities who
are on Medicaid rely on SSI. So I am confused about this
proposal which does not seem to protect the remaining 76
percent of children on Medicaid.
But let me ask another question to Ms. Miller and Ms. Mann
in my last remaining minute.
Three in five nursing home residents in Ohio rely on
Medicaid. I met Bob at a nursing home in Toledo and his mother,
Blanche, who lives in a home in Perrysburg. He said, ``My
mother and father worked all their lives. My mother is 95. You
have heard this story over and over and over in every community
in the country. They receive a pension of $1,500 a month.
Medicaid keeps her alive so she is able to spend time with her
kids and her grandkids.''
So, Ms. Miller, Ms. Mann, will quality nursing homes, like
the one Blanche relies on, be able to survive if Graham-Cassidy
passes?
Ms. Mann, you start.
Ms. Mann. Well, we talked about what the levers are for
being able to reduce cost. One is provider payments--reducing
provider payments. And that is usually the first place a State
will go, because it does not want to reduce eligibility or
benefits. And so we really worry about the risks to high-
quality nursing homes. High-quality providers will be affected
by the limitation on the dollars that States will have to
spend.
And if I could just respond to Senator Cassidy's statement
about disabled kids being exempted from the cap. They are
exempted from the calculation of the aggregate cap, and that is
an important feature of the definition of the cap. But at the
end of the day, the State has to meet a certain amount of
savings in order to stay below its aggregate cap.
And nobody in the Medicaid program, including kids with
disabilities, is going to be immune from the cuts that a State
will have to make to keep within its cap limits.
Senator Brown. Thank you, Ms. Mann.
I would just implore the chairman. John Kasich, my
Republican Governor, has run for office, has talked repeatedly
about repealing and replacing the Affordable Care Act, yet he
has the intellectual integrity to speak out on this,
understanding that when he expanded Medicaid, it meant 700,000
Ohioans got insurance.
I would love, Mr. Chairman, to have another hearing and
bring in Governor Kasich, bring in the Nevada Governor, who has
spoken about this, and bring in the Governor of Arizona, who
changed his position and said he supports it. Let us hear from
all of them. You know, let the winds on both sides blow through
this body so we can hear from them about why State Governors do
not like this proposal. They think it is a disaster for
Medicaid and consumer protections in my State.
The Chairman. Senator McCaskill?
Senator McCaskill. Thank you, Mr. Chairman.
While the CBO needs more time to fully evaluate this
legislation--and they probably do not have the latest version,
since it just happened today--they have very clearly said that,
all told, Federal spending on Medicaid would be reduced by a
trillion dollars over the 2017 to 2026 time period.
They have also said that many millions and millions of
people would lose coverage in the Medicaid program--and they go
through the three reasons that would happen--but also, this is
important, total enrollment in the non-group market would be
lower because the current-law subsidies for coverage in that
market would be eliminated and the individual mandate would be
repealed.
So more than half of this bill is about Medicaid. And every
example I hear about the problems with Obamacare are about the
individual market for people who do not get subsidies.
As said over and over again, but it bears repeating, every
example that the Republican Senators have cited has been about
people on the individual market without subsidies. And I know
that has gotten very expensive. That is where I buy my
insurance. I buy it on the individual market, and I do not take
any employer contribution. So I have seen my premiums go up,
and I know we need to do something to stabilize that.
But the notion that this bill is going to do that--there is
nothing in this bill that will do that.
The individual market, it is going to see less stability.
That is in the CBO report, and that is from everyone who has
looked at it. It is going to be a chaotic time in terms of the
timeline in which you are asking these States to come up with
an entire delivery system. There are going to be fewer people
in the market, not more. There is not going to be a mandate.
And not only are you going to ask these States to do more
with less and call it flexibility, you actually said that when
somebody shows up at the hospital without insurance, the State
is going to pay the bill. That is not going to happen. There is
not going to be money for that. That hospital at the end of the
year is going to call the insurance companies and say, we have
too much uninsured care, we are raising all your premiums. So
not only will premiums continue to go up in the individual
market, they are going to continue to go up in the employer
market because uninsured care is going to go up under this
plan.
And also, there is a big loophole I wanted to ask you about
on federalism. You have in your bill at one point that the
Federal Government is allowed to adjust how much States get
based on an adjustment factor.
And it says, on page 29 of the bill, that directs the
Secretary to consider legitimate factors that impact the
health-care expenditures in the State. But I could not find a
definition for ``legitimate factor.'' It gives that Secretary
an awful lot of power, does it not? Couldn't Secretary Price
say, ``Harvey is a legitimate factor, and I am taking a big
chunk of the money from other States to take it to Harvey?''
Senator Cassidy. No, that is a risk adjustment which is
commonly used in insurance. It uses age--elderly people are
obviously more expensive--disease burden, cost of living. So if
you are in a State like Pennsylvania, which has a higher cost
of living in Philadelphia, that would come in. It would be a
risk-adjustment factor which would allow movement of
something----
Senator McCaskill. But it is an open-ended----
Senator Cassidy. No, it is actually a very established
actuarial process, and it is currently being used in Texas, New
York, and other States. It can move you up 10 or down 10.
Senator McCaskill. Well, I am talking about the language of
the bill, Senator. I am talking about the language of the bill.
The language of the bill does not limit it. The language of the
bill leaves it open-ended.
Senator Cassidy. It is a risk-adjustment factor, and it is
commonly understood what it means.
Senator McCaskill. Well, it says ``legitimate factors.'' It
does not say ``risk.'' It says ``legitimate factors that impact
the health-care expenditures in a State.''
Senator Cassidy. And those are the actuarially important
factors.
Senator McCaskill. I do not think your bill is specific
about that. I think it leaves an awful lot of power where you
all are touting it no longer resides, and that is with the
Secretary of HHS.
I know that, Mr. Woodruff, you spoke eloquently about how
we are going to do more with less, we are going to stabilize an
individual market, we are going to take care of everyone who
does not buy insurance, we are going to make sure nobody has to
buy insurance. And by the way, all these States are going to
set all this up in less than 2 years.
Could you briefly talk, any of the witnesses, about the
feasibility of the timeline that is in this bill in terms of
States taking over this responsibility and having to file plans
as quickly as they will have to file plans?
And is it not possible they are just going to default to
traditional Medicaid?
Mr. Smith. I would be happy to address it, Senator. Again,
the time frame for filing an application is by March 31, 2019,
I believe, and then it goes into effect in 2020. And comments
were made earlier that there are a number of States that do not
meet all year round. But in fact, they have committees that
meet all year round. You have committees who go out and do
public hearings amongst the States all year round.
And I would suggest that all of the----
Senator McCaskill. They cannot legislatively act, though.
Mr. Smith. No, ma'am, but you can go out. You can go out
and develop----
Senator McCaskill. But having a hearing--I wish we could
legislatively act rather than just having a hearing. But
unfortunately, we cannot.
Mr. Smith. You can go out and build your plan. You can get
the input from the stakeholder community, from consumers, et
cetera, and put your options together so you are ready when you
do come back into legislative session. Many Governors can call
a legislature back into special session if need be.
But I think what makes this so very different from the ACA
and the long ramp-up to that versus where we are today is, the
ACA completely disrupted the distribution system, right? You
moved from an individual market that was based on insurance
agents and brokers marketing insurance plans. That all blew up
because it all got federalized. You had to build
HealthCare.gov, you had to do all of these things that
interrupted the distribution system.
We now have a distribution system. We have carriers that
are serving people whom they did not serve previously. They are
going to want to hold onto those customers. They are going to
want to continue to make it the easiest distribution system
possible, because otherwise they lose their customers.
So in all of the infrastructure, the technology that has
been developed over these past few years, States are not going
to throw that out. They are going to keep it. That is why you
are going to be able to implement this so much more quickly.
Senator McCaskill. I appreciate you jumping in.
I appreciate the chairman letting you go over for 2
minutes. I am not sure that he would have allowed the other
witnesses to go over for 2 minutes.
But I would have liked to hear from the witnesses who would
have talked about what a huge mountain this is to climb. But I
will have to wait for that.
The Chairman. Thank you, Senator.
Senator Cassidy, as a member of the committee, wants to ask
a question or two. And that will be fine. And then Senator
Wyden and I are going to wind this up.
Senator Cassidy. Okay. Senator Carper said, ``What have you
heard that just ain't so?'' So let me just go through some of
the notes that I have taken.
First, it has been a little ironic. On the other side of
the aisle, there has been a lot of, kind of, oh my gosh, States
cannot pull this off, but a lot of good comments by Senator
Carper about Romneycare in Massachusetts, a State initiative
which radically transformed the health care in Massachusetts,
was done quite successfully, and was being praised at the same
time we were told that it could not be done.
There were questions about stability funds. There are
stability funds in 2019 and 2020. And as we mentioned, there is
also a $2-billion implementation fund.
I will also point out that Senator Nelson talked about the
need in cases of public health emergency. There is $5 billion
in this fund for public health emergencies. And if there is
more needed, then more will be given. But it is specifically
excluded from that which they may have to do.
He also mentioned the need, in the State of Florida right
now, to get every dollar they can. We waive the Medicaid match,
and Florida ends up with 15 billion extra dollars than it has
right now.
Senator Stabenow suggested that we are cutting a trillion
dollars from Medicaid. No, we just repurpose it into other
areas. So the money is still there, available for the States.
Senator Bennet suggested that this is a transfer from
Democratic States to Republican States. Virginia is represented
by two Democratic Senators, Missouri by Senator McCaskill. Her
State ends up with $4 billion more between 2020 and 2026.
Senator McCaskill. Is that factored----
Senator Cassidy. By the way, on the issue of flexibility,
Senator Bennet also raised, oh, my gosh, there are folks in
your State, which I am totally about, Senator Bennet, totally
about, who cannot afford their insurance. This gives your State
the flexibility to do premium support, where if they cannot
afford the employees' contribution to be on employer-sponsored
insurance, you could do premium supports so they could get on
there.
Indeed, the report that just came out from CBO says that
they imagine that States would imitate successful programs in
one State and implement them in another.
There is also an issue of whether or not a restriction on
the amount of funding will restrict access. And Senator
Cantwell, whom I have learned so much from, she talks about how
her State gets less on a per-beneficiary basis on Medicare, so
they have had to innovate. And as they innovate, paradoxically,
they have actually improved outcomes. This is what we are
saying the potential is. And Senator Cantwell's State is one of
those States which has absolutely done it.
Let us see; Senator Brown suggested everything I have said
is fundamentally in error. That is actually an ad hominem
attack, which I think is actually beneath the dignity of this
body. And I am willing to, point by point, address whatever
Senator Brown thinks is wrong. But an ad hominem attack, I
think is beneath us.
Regarding people falling off of enrollment, there are all
these reports that people will fall off. Well, for Senator
McCaskill's point of view, for the Standard and Poor's study,
the Standard and Poor's study which says there is going to be
all these dire effects, they based that on the Avalere study.
The Avalere study scored us over 20 years, and this bill is
only for 10.
The Avalere study assumes for the next 10 years there is no
money whatsoever, but that is absurd. We actually renew
programs around here, as we do the CHIP program. And so the
Standard and Poor's study based upon the Avalere study is
frankly just not worthwhile.
As regards eliminating the individual mandate, aside from
the fact the American people hate it, one of the reasons they
voted for Donald Trump is because he promised to repeal it. It
also does not work. It does not work. And that is per Jonathan
Gruber. The fellow who was the architect of the Affordable Care
Act, in The New England Journal of Medicine reported research
that he did for the National Bureau of Economic Research in
which he said, and I am going to quote Mr. Gruber's comment,
``The individual mandate had no significant effect on coverage
in 2014.'' Now, he tries to say maybe it did, but he cannot
prove it.
Now, I am going to submit this for the record, Mr.
Chairman, Jonathan Gruber saying the individual mandate had no
effect. The CBO still credits it, even though it has no effect.
What does have an effect is a Governor getting engaged. If
a Governor gets engaged, he can, for example, do things like
automatic enrollment.
Senator McCaskill, the AEI also has a paper on how
automatic enrollment could be instituted so that those who
perhaps cannot get covered for whatever reason could be covered
automatically, just as we do on Medicare.
Let me finish by saying this. There is one thing we have
bipartisan agreement on. The Affordable Care Act is not
working. The proposal we have advanced has been called radical
today. But the alternative on the other side of the aisle is
single-payer. There are 15 cosponsors for Senator Sanders's
proposal, because it is a tacit acknowledgment that the
Affordable Care Act is not working.
And this I submit for the record, Mr. Chairman. These
yellow counties are the ones in which there is only one
insurance company covering. And the red ones, some of which are
in Missouri, are the ones in which there are no insurance
companies covering.
We have a problem. We can either go forward with the
single-payer option, which the other side of the aisle seems to
favor, or we can do what we have done with Massachusetts, with
Arkansas, with other States, giving them the opportunity to
implement. And perhaps like Washington State, they would
deliver better care at a lower cost. We actually think that
will happen.
Mr. Chairman, thank you for indulging me.
And by the way, by and large my colleagues have been civil.
You have been so respectful in a really good debate. I make no
defense of the process, but I do thank you. I thank you for
thinking carefully about it. I thank you for your civility. It
is a privilege to be in this body. I cannot praise you enough.
Thank you. I yield back.
The Chairman. Well, thank you, Senator. I think that you
have more than demonstrated civility yourself. And you did go
over, but that is okay. You have had all these people attacking
you all day; you should have a little more time as it is.
But we are going to now finish with Senator Wyden who
will--oh, Senator Bennet does have another question.
Senator Bennet. I am very grateful for your----
Senator Wyden. Just if my colleague will hold up.
Mr. Chairman, I did have a 5-minute closer. Senator
McCaskill apparently has something that is particularly
important to her, so she can take 5 minutes.
The Chairman. She will take your 5 minutes?
Senator Wyden. Yes.
Senator McCaskill. I will only need a minute.
Senator Wyden. Then I will immediately take my 4 back.
[Laughter.]
The Chairman. Well, I do not know. He gave up his 5
minutes. [Laughter.]
Go ahead.
Senator Bennet. I am going to try to be brief. And I want
to thank you, Mr. Chairman, for holding this hearing and for
your courtesy and graciousness throughout it, including
allowing me to ask a final question.
First, Mr. Chairman, like my colleagues, I would like to
submit for the record some letters from Colorado about this
bill.
The Chairman. They will be placed in the record.
Senator Bennet. Thank you.
[The letters can be viewed on the committee's website.]
Senator Bennet. I would also like to submit for the record
a study by the Kaiser Family Foundation about the percentage of
births that are financed by Medicaid.
The Chairman. Without objection, that will go in the record
as well.
Senator Bennet. Thank you.
[The study appears in the appendix on p. 91.]
Senator Bennet. And it is interesting just, Senator, to see
that Colorado is 43 percent of births financed, Alabama is 58
percent, Alaska is 53 percent, Arkansas is 67 percent. So I
think there is a lot we have to learn from each other, because
somebody is going to have to pay for these births.
Finally, Mr. Chairman, I would say, for the last 7 years,
the Republican Party has made repealing the Affordable Care Act
their defining issue. There were over 60 attempts in the House
of Representatives to repeal a law that helped over 600,000
Coloradans obtain access to health insurance.
But President Trump said he could do better and promised a
much more generous version--the Senator from Louisiana was
talking about his promise on the mandate--a much more generous
version of repeal and replace on the campaign trail. In
addition to promising repeatedly no cuts to Medicare and
Medicaid, he said, quote, ``Everyone has got to be covered. I
am going to take care of everybody. I do not care if it costs
me votes or not. Everybody is going to be taken care of much
better than they are taken care of today.''
When asked specifically about repeal and replace, he said,
``We are going to do it simultaneously. It will be just fine.
We are not going to have, like, a 2-day period and we are not
going to have a 2-year period when there is nothing. It will be
repealed and replaced and we will know. And it will be great
health care for much less money, so it will be better health
care, much better for less money. Not a bad combination.''
This is what he ran on; this was the commitment he made to
the American people. And I think on that basis, this piece of
legislation does not remotely honor that.
Mr. Chairman, I want you to know that I stand ready to work
with you and anybody else to meet the outcomes that the
President suggested when he was running for office.
The Chairman. Well, thank you.
Senator McCaskill, I understand you would like to make a
statement.
Senator McCaskill. Yes, I just have one question.
And I am sure that you may not have the answer. But if
possible, Senator Cassidy, I would like to know how much
Missouri will lose in terms of the provider tax. And we are
very, very reliant on the provider tax in my State. And so I
did not see any analysis of how you have offset that. If your
staff could provide what the provider tax would be in the
negative--I know that the shifting of money helps those States
that did not expand Medicaid, but I would like to know what
would be left after the provider tax is gone.
The Chairman. Would you do that for Senator McCaskill? If
you will submit that, I would appreciate it.
Senator McCaskill. Thank you.
The Chairman. Submit it to the whole committee, though, as
well, okay? All right.
Senator Wyden, you can make your closing remarks.
Senator Wyden. Thank you very much, Mr. Chairman.
Here is where we are with respect to this bill. Senator
Collins came out against this bill a little bit ago. So some
people are reporting this fight is over. My message to the
American people is that it is going to be critical to keep
fighting this deeply flawed bill, especially until Saturday,
which is when the next procedural window closes.
Two other concerns I have. When I asked Senator Cassidy
whether specifically this fifth version of the bill was it, it
seemed to me there was a little bit of fudging. And that is
another reason to keep fighting.
And then there has been an important development in the CBO
report that has not been referenced. I wanted to know
specifically whether there would be ironclad protections for
people with respect to those who have a pre-existing condition.
And Mr. Woodruff from the Cancer Society, who knows a little
bit about this subject, says no, there would not be ironclad
protections, because the States could waive them.
That is confirmed, colleagues, word for word in the CBO
report tonight.
Two last points, Mr. Chairman.
First, I really look forward to killing this flawed bill
and then going back to kind of positive work that you and I
want to do, that has really been our tradition, starting with
the Children's Health Insurance Program, and not have this kind
of abomination of a process ever again.
And, Mr. Chairman, I would just close by saying I ask
unanimous consent that a letter from Democratic members of the
committee requesting that we reconvene as soon as tomorrow to
continue this critical discussion could be made a part of the
record.
And I look forward to working with you.
[The letter appears in the appendix on p. 150.]
The Chairman. I think everybody has had enough time on this
right now, so we are not going to do that. But I do appreciate
your comments. And I appreciate working with you. It is a
pleasure for me, and you are a very, very fine man with a very,
very balanced approach towards these things.
Senator Wyden. Thank you. Thank you.
The Chairman. And while there is enough funding to ensure
CHIP services will be able to continue past the end of the
month, we certainly recognize that time is of the essence, and
we must act quickly to extend the funding for CHIP.
There has been strong support for this program in the
Senate Finance Committee, and that is why Ranking Member Wyden
and I have a bill out there to extend the program's funding for
5 years. It is not going to end, but we need to be careful
about re-upping it.
We are committed to working with our colleagues in both the
Senate and the House to act in swift order and develop a smart
and fiscally responsible solution that will ensure no lapse in
care for our Nation's most vulnerable children.
As the author of the CHIP bill--and I think everybody knows
that I was able to talk to my friend Senator Kennedy, and in
fact he leapt over across the divide to join me on the CHIP
bill and it was one of his proudest achievements. As the author
of that bill, I can say that that bill has done an awful lot of
good, and I want to make sure that nobody fouls it up.
I would encourage my colleagues to work with the HELP
committee to extend and pay for community health centers. That
is where that is, and we need to work hard to do that.
I want to personally thank this group of witnesses today.
It has been a really hard thing to sit there all of this time
and answer the questions that you have. You have all been just
stellar as far as I am concerned, and I think very highly of
you.
Some of you I agree with more than others, of course, but
that is always the case. And all I can say is that I hope we
can reach a point someday in our lives around here where the
answer to everything is not more money that we do not have,
that the answer to everything is not more Federal Government
that we do not need.
And the answer around here is that we can work together to
try to solve these problems without bankrupting the country. As
you can see, we are already in real difficulty because of the
health care situation in this country. And the Affordable Care
Act is anything but affordable and everybody knows it. Most
people, at least on one side, do not want to admit it, but it
is true. And we are going to be in real trouble if we do not
turn this thing around.
But I want to especially thank our witnesses for being
here.
I want to thank everyone for their attendance and
participation today.
Like I say, I would especially like to thank our witnesses
for providing the testimony and expertise today. You have all
been just really good as far as I am concerned.
For any of my colleagues who have written questions for the
record, I ask that you submit them by close of business
Wednesday, September 27th.
And so with that, you will be happy to hear, you folks who
have sat there all day so patiently, the hearing is adjourned.
[Whereupon, at 7:10 p.m., the hearing was concluded.]
A P P E N D I X
Additional Material Submitted for the Record
----------
Submitted by Hon. Michael F. Bennet, a U.S. Senator From Colorado
Changes to Federal Spending for ACA Under Graham-Cassidy
($Millions), 2020-2026
Colorado
Current Law Federal Funds for ACA Coverage: $17,706
Federal Funds Under Block Grant Program: $15,419
Difference ($): -$2,288
Difference (%): -13%
Total Change in Federal Spending Under Graham-Cassidy Due to ACA Block
Grant and Medicaid Per Capita Cap ($ Millions), 2020-2026
Colorado
Change in Federal Funds Due to Block Grant: -$2,288
Change in Federal Funds Due to Medicaid Per Enrollee Cap: -$573
Total Change in Federal Funds ($): -$2,860
Total Change in Federal Spending Under Graham-Cassidy Due to ACA Block
Grant and Medicaid Per Capita Cap ($ Millions), 2027
Colorado
Loss of Federal Funds for ACA Coverage if Congress Does Not Extend
Block Grant:
-$3,172
Loss of Federal Funds Due to Medicaid Per Enrollee Cap: -$164
Total Loss of Federal Funds: -$3,335
Source: The Henry J. Kaiser Family Foundation, ``State-by-State
Estimates of Changes in Federal Spending on Health Care Under the
Graham-Cassidy Bill,'' September 2017, http://files.kff.org/attachment/
Issue-Brief-State-by-State-Estimates-of-Changes-in-Federal-Spending-on-
Health-Care-Under-the-Graham-Cassidy-Bill.
______
The Henry J. Kaiser Family Foundation
Births Financed by Medicaid
Time frame: Varies by State
_______________________________________________________________________
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
------------------------------------------------------------------------
Percent of Percent of
Births Births
Location Financed by Location Financed by
Medicaid Medicaid
------------------------------------------------------------------------
Alabama 58% Alaska 53%
------------------------------------------------------------------------
Arizona 54% Arkansas 67%
------------------------------------------------------------------------
California 50% Colorado 43%
------------------------------------------------------------------------
Connecticut 47% Delaware 48%
------------------------------------------------------------------------
District of Columbia 46% Florida 50%
------------------------------------------------------------------------
Georgia 54% Hawaii N/A
------------------------------------------------------------------------
Idaho 45% Illinois 50%
------------------------------------------------------------------------
Indiana 50% Iowa 37%
------------------------------------------------------------------------
Kansas 34% Kentucky 46%
------------------------------------------------------------------------
Louisiana 65% Maine 43%
------------------------------------------------------------------------
Maryland 44% Massachusetts 41%
------------------------------------------------------------------------
Michigan 46% Minnesota 43%
------------------------------------------------------------------------
Mississippi 64% Missouri 42%
------------------------------------------------------------------------
Montana 49% Nebraska 35%
------------------------------------------------------------------------
Nevada 64% New Hampshire 27%
------------------------------------------------------------------------
New Jersey 42% New Mexico 72%
------------------------------------------------------------------------
New York 51% North Carolina 54%
------------------------------------------------------------------------
North Dakota 33% Ohio 52%
------------------------------------------------------------------------
Oklahoma 60% Oregon 50%
------------------------------------------------------------------------
Pennsylvania 39% Rhode Island 50%
------------------------------------------------------------------------
South Carolina 60% South Dakota 50%
------------------------------------------------------------------------
Tennessee 54% Texas 54%
------------------------------------------------------------------------
Utah 31% Vermont 42%
------------------------------------------------------------------------
Virginia 31% Washington 49%
------------------------------------------------------------------------
West Virginia 48% Wisconsin 64%
------------------------------------------------------------------------
Wyoming 36% United States N/A
------------------------------------------------------------------------
Notes
In the 2016 Kaiser Family Foundation Medicaid Budget Survey, States were
asked to report the share of all births in the State that were
financed by Medicaid in the most recent 12-month period for which data
were available. States reported data from 2010-2016, which varied by
calendar year, State fiscal year, and Federal fiscal year.
Sources
Vernon K. Smith, Kathleen Gifford, Eileen Ellis, and Barbara Edwards,
Health Management Associates; and Robin Rudowitz, Elizabeth Hinton,
Larisa Antonisse, and Allison Valentine, Kaiser Commission on Medicaid
and the Uninsured. ``Implementing Coverage and Payment Initiatives:
Results from a 50-State Medicaid Budget Survey for State Fiscal Years
2016 and 2017,'' The Henry J. Kaiser Family Foundation, October 2016.
Definitions
N/A: Data not available.
Prepared Statement of Hon. Bill Cassidy, M.D.,
a U.S. Senator From Louisiana
My colleagues, it is a privilege to speak to the Graham-Cassidy-
Heller-Johnson amendment to H.R. 1628, the American Health Care Act.
Before being Senator Cassidy, I was Dr. Cassidy, caring for
uninsured and Medicaid patients in Louisiana's public hospital system.
My patients had terrible disease, multiple chronic conditions but could
not receive care elsewhere. My life work has been to care for such
fellow Americans. This bill continues this work by other means.
The ACA promised affordable health-care coverage, freedom to keep
your doctor and to bring health-care costs down. In reality, middle-
class families have sky-
rocketing premiums, individual mandates which Americans hate, $6,000
deductibles in a failing individual market. The projected inflation
rate of the exchange tax subsidies and the cost sharing reduction
payments is 12.9% per year; doubling the expense every 6 years. The
State match for the Medicaid Expansion increases to 10% in 2020. This
can be in the millions and billions. Fifteen Democratic Senators
recently declared Obamacare a failure while endorsing a single payer
system. The problems of Obamacare require a path forward.
Some today will bewail that Republicans won't give up attempts to
repeal Obamacare. This Republican will continue to do so as long as
premiums and deductibles for middle-class families grow 10% to 50% or
even higher per year, destroying family budgets.
As a positive, Senator Wyden recently praised the CHIP program. We
agree. GCHJ passes a flexible block grant combining Medicaid Expansion,
Obamacare tax credits, cost-sharing reduction subsidies and the basic
health plan, and distributes this money through the CHIP program with
CHIP requirements and protections. It is a mandatory appropriation. The
CHIP program requires reauthorization. This does not mean it
automatically goes away in 10 years as some absurdly state.
States receive an allocation based on how many Americans between
50% and 138% FPL live in the State. Over the course of years, the
amount the Federal taxpayer provides per person equalizes so that no
matter where the American lives, they benefit equally.
Let me address the inevitable comment that we end Medicaid
expansion. A State can continue to fund their expansion program as they
have implemented. They have the flexibility. Despite pointing this out,
it will be said.
To help States, Medicaid Expansion match is waived. The flexible
block grant functions like a combined section 1115/1332 waiver with
guardrails providing States flexibility to innovate. We preserve
patient protections such as mental health parity, guaranteed issue,
prohibit charging women more for health insurance and no lifetime caps.
States applying for waivers must prove that Americans with pre-existing
conditions have access to affordable and adequate coverage--period, the
end. I'm asked what is the definition of affordable. It means the
patient can afford it.
This raises an issue, many on the left are threatened that we give
States and patients the power Obamacare usurped. Under this narrative,
States are inept, corrupt Governors scheme to deprive his or her
State's residents of protections, and patients only get better if told
what to do. This amendment rejects that narrative.
GCHJ repeals the individual mandate which ACA architect Jonathon
Gruber, found does not increase enrollment. Regarding this, the IRS
reports that 58% of those penalized have AGI of less than $50,000. We
think these Americans should be helped, not penalized. GCHJ repeals the
employer mandate, which data shows decreases full time employment
opportunity for the lowest quintile of wage earners, those who can
least afford.
Today, I expect accusations that this is a partisan bill which
drains Blue States for the sake of Red States. Totally false. Under the
latest version, Virginia receives $4 billion more from 2020 to 2026,
Missouri $5 billion more, and Florida $15 billion more than current
law; increasing access to coverage for things like colonoscopies,
mammograms and other screening tests for millions. Those opposing this
amendment clearly don't care about Americans in these and similar
States.
I also expect pleas for regular order. Why don't we just have
hearings. I don't defend this process, but I will say that no Democrat
was interested in addressing the problems with Obamacare in my State
when Susan Collins and I crafted a bill allowing States to keep
Obamacare if it was working while allowing other States where Obamacare
failed to try something else. There was no interest whatsoever. I
wanted the effort to be bipartisan. But, if one side of the aisle
refuses to help my State, I can't stop trying.
We need to pass the Graham-Cassidy-Heller-Johnson amendment,
returning power to patients and States while expanding access to
coverage for millions. Thank you.
______
Questions Submitted for the Record to Hon. Bill Cassidy
Question Submitted by Hon. Claire McCaskill
Question. Do your calculations of the State-by-State impact of
Graham-Cassidy-Heller-Johnson include the effect of lowering the
provider tax safe harbor limit under the hold harmless rule to 4
percent?
If not, will you please provide a State-by-State calculation of
reduction in State and Federal Medicaid dollars due to the lowering of
the provider tax safe harbor limit under the hold harmless rule to 4
percent, based on current utilization of the safe-harbor limit?
Answer. The analysis on the latest version of Graham-Cassidy
legislative text can be found on our website at https://
www.cassidy.senate.gov/read-about-graham-cassidy-heller-johnson. You
will have to contact OMB regarding the assumptions behind the model and
whether lowering the cap on the provider tax was incorporated into
their modeling on a State-by-State basis.
______
Questions Submitted by Hon. Robert Menendez
Question. You dispute the analyses by several outside organizations
about the impact of your proposal on coverage rates and funding to
States. Can you provide your analysis on how New Jersey would fare
under your proposal each year through 2036 in terms of premiums in the
State, number of covered individuals using 2016 census data as a
baseline, impact to the economy of the State, funding for New Jersey
under your Medicaid block grant, funding under the Market-Based Health
Care Block Grant, and the impact to hospitals in the State?
Answer. No such analysis exists for this legislation, nor has it
existed in such detail for any piece of legislation ever. Even CBO does
not do analysis as detailed as you are requesting. Furthermore, the
legislative text can only run through 2026 per reconciliation rules,
therefore any analysis beyond 2026 on the block grant, premiums, and
impact on hospitals is inaccurate and thoroughly misleading. Finally,
States are given significant flexibility in determining how to best
serve their patient populations, therefore trying to predict and
measure these decisions and the impact on premiums and hospitals over a
20-year period is purely speculative.
OMB recently released a report of the dollars received under the
Market-Based Health Care Grant Program (https://www.cassidy.senate.gov/
read-about-graham-cassidy-heller-johnson) that indicates New Jersey
would be held harmless compared with current law when taking into
account that the State would no longer have to put up its 10% match for
the Medicaid expansion population.
Question. Can you provide detailed information on how you are
modeling your impact data, including showing me the inputs,
assumptions, and formulas you used to find the New Jersey numbers under
your proposal through 2036 for each of the impact data points requested
in Question 1 above?
Answer. The analysis on the latest version of Graham-Cassidy
legislative text can be found on our website at https://
www.cassidy.senate.gov/read-about-graham-cassidy-heller-johnson. You
will have to contact OMB regarding the assumptions behind their model.
In our initial numbers, we based these numbers off of spending in
2016 on CSRs, tax credits, and Medicaid expansion as provided by HHS/
CMS/OMB and updated for any new data presented by State Medicaid
directors where appropriate. These numbers were then grown by CPI-M
each year until 2020 to determine the base rate. The formula then kicks
in to grow and adjust the numbers as written in the legislative text.
Question. The United States is facing a rapidly aging population.
Medicaid pays for the long-term care needs of millions of seniors, a
number that is expected to grow rapidly in the near future. How will
your funding caps for Medicaid funding impact the ability of States to
meet the needs of the elderly? In particular, can the needs of the
growing number of individuals afflicted by Alzheimer's disease be met
with your plan?
Answer. We have asked OMB to provide an analysis of the per-capita
cap on a State-by-State basis. It is important to note that this type
of proposal was originally put forward by President Bill Clinton and
endorsed by every Senate Democrat at the time, including three current
Senators and the former Vice President. Our proposal provides a growth
rate above medical inflation through 2024 and then a growth rate of
medical inflation after that. Currently, long-term care is growing at a
lower rate annually than this level. We believe the growing needs of
the long-term care population, including those battling Alzheimer's can
and would be addressed under this proposal.
Question. Families who have children with special needs often face
an uphill battle in accessing services. What protections does your bill
offer them to ensure their children are not cut off from care for their
conditions? How will you ensure that a young child isn't forced to go
without care because they have hit an annual cap? A lifetime cap?
Answer. The legislation does not change the prohibition on denying
coverage for individuals with pre-existing conditions. It also does not
alter the requirements of guaranteed issue, guaranteed renewability, or
community rating. While it does give States the ability to alter the
essential health benefits in its application for the block grant, it
does not change the prohibition on annual or lifetime caps and it
requires States to certify that they will ensure individuals with pre-
existing conditions have access to adequate and affordable coverage.
CRS has done a report certifying that granting flexibility on essential
health benefits does not eliminate the prohibitions on annual and
lifetime caps. This flexibility on essential health benefits is also
envisioned under section 1332 of PPACA.
Question. How will your plan ensure there is no massive disruption
of the individual insurance market should it be enacted in the period
of time before the
Market-Based Health Care Block Grants (HCBG) are released to States?
Answer. The bill provides $10 billion in 2019 and $15 billion in
2020 for short-term market stabilization. Furthermore, I have
cosponsored the Alexander-Murray proposal to stabilize the individual
insurance market. My fellow authors and I have always made clear that
short-term stabilization would be necessary under any proposal and that
we support the need to do this as a bridge to our proposal.
Question. Wrap-around services are of critical importance to many
families who have children with disabilities and who earn too much to
qualify for Medicaid. How will your proposal ensure these families
don't lose access to critically important services for their children
and family members?
Answer. Under this proposal, up to 20% of the funds under the block
grant can be used for optional benefits and wrap-around services under
the traditional Medicaid program. This was specifically done to ensure
that States can maintain successful wrap-around services and optional
benefits with the implementation of a per-capita cap. We support giving
States the flexibility and the funding to best serve the populations in
their States.
Question. The HCBS demonstration project funding is a positive
addition; however as written, would States currently using those funds
be able to use this funding for the same services they are providing
today?
Answer. This legislation creates a 4-year, $8-billion competitive
demonstration project to fund home and community-based services.
Participating States would have an FMAP of 100% for these services.
Furthermore, a State may use up to 20% of its block grant dollars on
wrap-around and optional services under the traditional Medicaid
program, so a State would have the ability to use those dollars to
create its own program for HCBS if it so chooses.
Question. Does the innovation fund replace the amount of HCBS
funding lost due to the repeal of the 1915(k) enhanced match?
Answer. The combination of the dollars in the demonstration project
and the 20% option in the block grant will more than cover the amount
currently spent on HCBS.
Question. Are States and CMS able to identify the children with
autism eligible for Medicaid on the basis of income?
Answer. I will defer to CMS on this question.
Question. Will children with autism who are eligible for Medicaid
on the basis of income be able to be excluded from the cap?
Answer. Blind and disabled children are exempted from the per-
capita cap. This is defined as children under age 19, who are eligible
for Medicaid based on their disability. This determination is made on a
State-by-State basis based on a medical diagnosis that fits the State's
definition of being medically needy in an eligibility pathway. For some
States, autism may be a medically needy pathway for Medicaid coverage,
while it may not in others.
Question. If those children with autism who are eligible for
Medicaid on the basis of income are included in the cap, what do you
anticipate will be the impact on States' ability to meet their
obligations under Early and Periodic Screening, Diagnostic, and
Treatment?
Answer. There can be no cuts to EPSDT, so the full range of
services would be built into the child-specific cap.
Question. As of August 2017, NJ FamilyCare provides coverage for
over 205,000 New Jerseyans with disabilities. For many people with
disabilities, Medicaid is about more than simply medical care. Not only
is it about life, but about liberty and the pursuit of happiness as
well. This legislation stands to erode the great progress made in the
nearly three decades since the passage of the Americans with
Disabilities Act of 1990 on the ability of people with disabilities to
integrate into the community. What would the impact of this legislation
be on the ability of States to provide for home and community-based
services for people with disabilities through Medicaid? What impact
would the Medicaid per-capita caps and the end of consumer protections
for essential health benefits have on the ability of people with
disabilities to live independently and contribute to their communities?
Answer. The growth rate for the per-capita cap for the disabled
population is set above medical inflation through 2024 and then moves
to medical inflation starting in 2025. This will give States
significant resources to provide services to individuals with
disabilities, including HCBS. Furthermore, there is a demonstration
project with $8 billion for HCBS. Finally, up to 20% of the dollars
under the block grant can be used for services like HCBS under
traditional Medicaid. States will have significant and sufficient
resources to help people with disabilities live independently and
contribute to their communities.
Question. What would the impact of this legislation be on the
ability of States to provide for home and community-based services for
people with disabilities through Medicaid?
Answer. There is a demonstration project with $8 billion for HCBS.
In addition, up to 20% of the dollars under the block grant can be used
for services like HCBS under traditional Medicaid.
Question. What impact would the Medicaid per-capita caps and the
end of consumer protections for essential health benefits have on the
ability of people with disabilities to live independently and
contribute to their communities?
Answer. The growth rate for the per-capita cap for the disabled
population is set above medical inflation through 2024 and then moves
to medical inflation starting in 2025. This will give States
significant resources to provide services to individuals with
disabilities. In addition, up to 20% of the dollars under the block
grant can be used for services like HCBS under traditional Medicaid.
States will have significant and sufficient resources to help people
with disabilities live independently and contribute to their
communities.
Question. How will the changed funding to the Medicaid impact the
program's ability to respond to catastrophic events like floods and
hurricanes? Will States have the funding they need to respond to a
spike in Medicaid need through your proposal?
Answer. Spending attributed to a public health emergency would be
exempted from the per-capita cap up to $5 billion from 2020-2024. A
public health emergency is defined by a declaration by the Secretary
pursuant to section 319 of the Public Health Service Act.
______
Questions Submitted by Hon. Bill Nelson
Question. Eleven seniors in Florida died after being trapped in a
nursing home in extreme temperatures after Hurricane Irma knocked out
the facility's power. Most troubling is that there was a functioning
hospital located directly across the street from the nursing home, and
yet they weren't evacuated. There's an ongoing criminal investigation
to determine what went wrong and who is to blame, but quite simply,
this isn't acceptable.
Nursing homes and other long-term care facilities are under
tremendous pressure to provide quality care and take care of our loved
ones, but they need the resources in order to do so.
The Graham-Cassidy bill caps Medicaid, effectively cutting billions
from the program. The cap would grow more slowly each year than the
projected growth in State per-beneficiary costs, especially over time
with an aging population. The cuts to Federal Medicaid funding would
only deepen in 2025 as the annual adjustment becomes even more
inadequate.
This is especially problematic for Florida, as the rate of Medicaid
enrollment for disabled persons and low-income seniors has risen faster
than the national average over the last 10 years.
Moreover, the cap would force States to make hard choices about
cutting eligibility, benefits, and/or provider payments. Many States
will be faced with no choice but to cut-home and community-based
services, and other ``optional'' benefits.
Do you believe the Graham-Cassidy bill would allow nursing homes,
home health agencies, and other long-term care facilities to provide
quality care to the Nation's seniors?
Answer. Yes, the Graham-Cassidy bill would allow nursing homes,
home health agencies, and other long-term care facilities to provide
quality care to the Nation's seniors. The growth rate for the per-
capita cap for the long-term care population is set above medical
inflation through 2024 and then moves to medical inflation starting in
2025. This will give States significant resources to provide services
to individuals with disabilities. Currently, long-term care is growing
at a lower rate annual than this level. In addition, up to 20% of the
dollars under the block grant can be used for wrap-around and optional
services under traditional Medicaid that could be used to serve the
long-term care population.
Question. Twenty-five percent of Florida's population or 5 million
Floridians are 60 or older, making Florida the State with the largest
population of seniors. Generally older adults have more health care
needs, chronic conditions and co-morbidities than younger people. Many
older Americans are also forced to tighten their belts to afford things
like health coverage.
Please tell me with a ``yes'' or ``no'' answer, does the Graham-
Cassidy bill repeal the ACA's premium tax credits?
Answer. The Graham-Cassidy bill repeals the ACA's premium tax
credits in 2020 and replaces that funding with dollars given to States
through a block grant. The amount of dollars in 2020 is based on the
amount of money received by States or individuals in the State for tax
credits, Medicaid expansion, cost-sharing reduction subsidies, and
basic health program in 2017 grown by medical inflation until 2020.
Question. Does the Graham-Cassidy bill eliminate cost-sharing
reduction payments?
Answer. The Graham-Cassidy bill repeals the ACA's cost-sharing
reduction subsidies in 2020 and replaces that funding with dollars
given to States through a block grant. The amount of dollars in 2020 is
based on the amount of money received by States or individuals in the
State for tax credits, Medicaid expansion, cost-sharing reduction
subsidies, and basic health program spending in 2017 grown by medical
inflation until 2020.
Question. Does the Graham-Cassidy bill allow States to take us back
to the days when insurers could charge older adults higher rates than
under the existing law?
Answer. States would have the flexibility to change age rating
rules provided that individuals with pre-existing conditions have
access to adequate and affordable coverage and the Secretary approves
their application.
Question. The opioid crisis is devastating families across the
country. In Florida alone, 2,600 people died from opioids in the first
half of 2016. Fentanyl was responsible for 704 of those deaths.
The Affordable Care Act made great strides to increase access to
substance abuse treatment. It ensured that newly covered individuals
would receive mental health and substance use disorder services,
including behavioral health treatment, under their health insurance
plan as part of their essential health benefits.
Is substance use disorder treatment a necessary component of
efforts to prevent and treat opioid addiction?
Answer. As a physican who has taken care of patients with substance
abuse disorder, I know that treatment is an important part of
preventing and treating opioid addiction.
Question. Does the Graham-Cassidy bill allow States to waive
essential health benefits, like coverage of mental health and substance
use disorder services?
Answer. States have the ability to apply to alter the essential
health benefits in its application for the block grant. In order for an
application to be approved, States must certify that individuals with
pre-existing conditions have access to adequate and affordable
coverage. This same flexibility on essential health benefits is also
envisioned under section 1332 of PPACA.
Question. By capping the Medicaid program and ending Medicaid
expansion, the Graham-Cassidy bill cuts billions of dollars from
Medicaid, the largest payer of substance use services in the country. A
September 25th CBO report Stated that the Graham-Cassidy bill cuts $1
trillion out of Medicaid over 10 years. If those cuts are made, how do
you propose States like Florida provide the necessary services to help
individuals with substance use disorders?
Answer. This is a misleading statement. While the amount of money
projected to be spent on Medicaid is reduced as compared to current
law, much of this money is still given to States through the Market-
Based Health Care Grant Program. In total more than $1.2 trillion is
put into this block grant. Furthermore, the rate of growth for the per-
capita caps are placed at medical inflation and medical inflation plus
1% through 2024. For many States and categories of patients in the
Medicaid population, this is above the current rate of spending
projections.
Question. Some have said that the public health emergency response
fund could be used for the opioid epidemic; however, it is my
understanding that this money was for disasters like Hurricane Irma.
Does that mean flood victims and those suffering from opioid addiction
will be pitted against each other?
Answer. Spending attributed to a public health emergency would be
exempted from the per-capita cap up to $5 billion from 2020-2024. A
public health emergency is defined by a declaration by the Secretary
pursuant to section 319 of the Public Health Service Act. In addition,
up to 20% of the block grant can be used on the traditional Medicaid
population, giving States significant flexibility and resources to help
with health spending related to the opioid epidemic and Hurricane Irma.
Furthermore, Congress usually passes supplemental appropriations to
help with disaster spending that exceeds the current amount of money
appropriated to the disaster fund.
______
Prepared Statement of Hon. Lindsey Graham,
a U.S. Senator From South Carolina
Health care in the United States is in the throes of an unrelenting
tailspin. Thrust upon us on Christmas Eve in 2009, Obamacare has been
an unmitigated disaster. Premiums are growing at unsustainable rates;
insurers are fleeing exchanges and dropping coverage, and patients
across the country are in many cases down to a few, or in some cases
zero options to purchase coverage.
In my State of South Carolina, we are down to one carrier offering
coverage in the exchange. In 2014, we had five carriers. Exchange based
plans are relied on by around 200,000 people in South Carolina.
Premiums are set to rise over 30% in South Carolina next year alone.
Across the country, the situation is no better. Next year, it is
expected that 45 percent of all counties in America will have either
one or no carriers offering coverage--impacting coverage where 12
million people live.
Medicaid and health-care spending are on an unsustainable spending
trajectory. Four high-spending States, California, New York, Maryland,
and Massachusetts are receiving a disproportionate share of all
Obamacare funds. They are receiving nearly 40% of all Obamacare
spending, with only just over 20% of the country's population. This is
not only inequitable, but unsustainable. Graham-Cassidy-Heller-Johnson
restores parity among the States and reforms spending inefficiencies.
Today we stand at a defining crossroads--with three options: (1)
Prop up Obamacare; (2) Berniecare, as introduced by Senator Bernie
Sanders, or (3) Graham-
Cassidy-Heller-Johnson.
Do we continue the march to single-payer through Obamacare, and now
Berniecare, or do we empower the States to design patient-centered
health care in the local communities where patients live?
Graham-Cassidy-Heller-Johnson embraces federalism and takes the
power and money to direct health care out of Washington and to the
States. Our proposal is the last best chance to end the march to
single-payer healthcare. It is single-payer's worst nightmare.
We are in the defining fight for the future of health care in
America. Obamacare has failed. Berniecare is the end of patient choice
and innovation. Graham-Cassidy-Heller-Johnson is the last and best hope
to empower patient-centered health care in America.
It is supported by as wide a coalition as President Donald Trump,
Governor Jeb Bush, Alan Greenspan, and Breitbart. Most importantly,
Repeal and Replace is being demanded of us by the American people. We
hear their call to action, and are ready to pass Graham-Cassidy-Heller-
Johnson.
My cosponsors and I, this band of brothers, are here to fight for
health-care freedom, until Graham-Cassidy-Heller-Johnson becomes the
law of the land.
______
Prepared Statement of Hon. Orrin G. Hatch,
a U.S. Senator From Utah
WASHINGTON--Senate Finance Committee Chairman Orrin Hatch (R-Utah)
today delivered the following opening statement at a hearing on the
Graham-Cassidy-
Heller-Johnson health-care proposal.
I'd like to welcome everyone to this afternoon's hearing where we
will discuss and examine the Graham-Cassidy-Heller-Johnson health-care
proposal.
Given the relatively unique circumstances we're facing with regard
to health care generally and this proposal in particular, the Senate
Republican leadership as well as members of the conference have asked
for a hearing on this proposal so that we can all get a better sense of
how it is intended to work.
Toward that end, we have two distinguished panels of witnesses
before us today.
The first panel will feature statements from two of our
distinguished Senate colleagues.
The second panel will feature another one our colleagues, who is
also a member of this committee. We'll hear from a friend and former
Senate colleague on the second panel as well. Joining them at the table
will be experts and stakeholders who are here to share their views on
the proposal from Senators Graham, Cassidy, Heller, and Johnson.
The purpose of a hearing is to respectfully discuss ideas and
become better informed on particular issues. It does not mean that
everyone shares the same views and opinions.
In fact, I expect that quite a few disagreements will be expressed
today. And that is okay.
I've been in the Senate for 4 decades now. And in that time, I've
been a part of some very difficult and contentious debates.
Early on, I was part of a fierce debate over labor law reform.
Over the years, I've participated in some of the most heated
Supreme Court hearings in our Nation's history.
I was here to take part in drafting, debating, and passing the
Americans with Disabilities Act, one of my proudest accomplishments.
I was around when the debate over the war in Iraq became extremely
combative.
And of course, I was here when we debated Obamacare before it
passed, and I've been here for every debate we've had about it since
that time.
So I understand that there are some strong opinions about this
issue. And more importantly, I understand why opinions are so strong.
When we talk about health-care policy, we're not just talking about
a theoretical concept or legislation that impacts a single isolated
industry. This topic has a significant impact on the lives of every
person in this country in ways that can make or break both their health
and their livelihoods.
Frankly, because this issue is so personal, everyone has strong
feelings.
To members of the committee, to those in the audience today, and to
any person who may watch or read about today's hearing at some point in
the future, let me say this: I respect your opinions on these issues.
But, while I wish that expressions of goodwill could, on their own,
fix our Nation's problems, that is just not the case. We have to do the
work. And, on these issues, the work is particularly hard.
Today, we're here to discuss the most recent health-care proposal
drafted by some of our colleagues. I commend them for their efforts and
their willingness to put forward ideas to address these problems.
My hope is that we can spend our time today questioning our
witnesses about substance and policy and not on scoring political
points, particularly when we have distinguished colleagues and a former
colleague at the witness table.
I know that, for both sides of this debate, passionate
demonstrations and righteous indignation--particularly when there are
cameras in the room--make good fodder for Twitter and TV commercials,
especially when the subject is health care. Our committee is generally
regarded as being above such shenanigans, though we haven't been
entirely immune to these types of theatrics in the past.
For today, let me say this. If the hearing is going to devolve into
a sideshow or a forum simply for putting partisan points on the board,
there's no real reason for us to be here. I won't hesitate to adjourn
the hearing if it gets to that point. I'm saying this for the benefit
of my colleagues on the committee and everyone in the audience.
Let's have a civil discussion.
I have no objection to having a spirited debate on these issues. My
hope is that, in the end, our efforts will generate more light and less
heat than we've seen in the most recent episodes of the health-care
debate. If we can't have that, we should all be spending our time on
something more productive.
______
Prepared Statement of Hon. Mazie K. Hirono,
a U.S. Senator From Hawaii
Chairman Hatch, Ranking Member Wyden, members of the committee,
thank you for holding today's hearing. We may not agree on much when it
comes to health care, but we all agree that the legislation we are
considering today will have a tremendous impact on families in every
State in this Nation.
Nearly every health-care stakeholder--insurers, doctors, hospitals,
patient groups, state governments, and others--has raised serious
concerns about, or outright opposes this bill. Its details are
complicated, its impact is very broad, and it's ridiculous that this
will be the only hearing on this bill before the Senate votes on it.
I urge my colleagues: let's do what's right for the millions of our
constituents and their families, set this bill aside, and work together
to find bipartisan agreement to strengthen the Affordable Care Act.
______
Prepared Statement of Cindy Mann,\1\ Former Deputy Administrator and
Director of the Center for Medicaid and CHIP Services, Centers for
Medicare and Medicaid Services, Department of Health and Human Services
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\1\ Application for admission to the District of Columbia Bar
pending. Practicing under the supervision of Jill DeGraff, a member of
the District of Columbia Bar. Admitted to practice in New York and
Massachusetts.
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Good morning Chairman Hatch, Senator Wyden, and distinguished
members of committee. Thank you for the invitation to participate in
this hearing on the
Graham-Cassidy-Heller-Johnson legislative proposal (referred to
hereafter as
``Graham-Cassidy'').
I am Cindy Mann, a partner at Manatt, Phelps, and Phillips. At
Manatt, I work with States, health-care providers and provider
organizations, foundations, and consumer organizations, on matters
relating to health-care coverage, delivery system reform, and
financing, focusing primarily on publicly financed coverage and
particularly, Medicaid and the Children's Health Insurance Program
(CHIP). I also currently serve as an advisor to the Bipartisan Policy
Center on the future of health care. Prior to joining Manatt, from June
2009 through January 2015, I served as Deputy Administrator for the
Centers for Medicare and Medicaid Services (CMS) and as Director of the
Center for Medicaid and CHIP Services. In that capacity, I was
responsible for Federal policy and oversight of Medicaid and CHIP and
for supporting State implementation of those programs. While at CMS,
much of my focus was working with States as they implemented provisions
of the Affordable Care Act. Prior to joining CMS, I was a research
professor at Georgetown University's Health Policy Institute and
founded the Center for Children and Families, a research and policy
organization focused on children's coverage. I also served as the
Director of the Family and Children's Health Programs Group at the
Health Care Financing Administration (now CMS), where I directed
Federal implementation of CHIP and Medicaid with respect to children,
families and pregnant women from 1999 to 2001. I have over 30 years of
experience in these matters both at the Federal level and in States.
My testimony today highlights the impact of the legislative
proposal introduced by Senators Graham, Cassidy, Heller, and Johnson to
repeal and replace the Affordable Care Act, focusing particularly on
the impact on Medicaid and the 74 million people served by the Medicaid
program. My testimony draws, in part, on an analysis of the Graham-
Cassidy proposal prepared by Manatt Health on behalf of the Robert Wood
Johnson State Health and Value Strategies Project; that report is
attached.
The Graham-Cassidy proposal would create new and far-reaching risks
for people, States and the health-care system.
Through funding reductions and caps, it puts coverage at risk
for virtually every group of individuals covered through
``traditional'' Medicaid, including one out of three children in the
Nation as well as millions of elderly and people with disabilities
whose long-term care services are covered by Medicaid.
It will also harm--and in some cases pose life-threatening
harm--to the 23 million people projected to be covered through the
Medicaid expansion and the Marketplace in 2019, who, by the terms of
this proposal, will lose their coverage on December 31, 2019.
And for those purchasing coverage in the individual and small
group market, Graham-Cassidy will trigger in the very short term new
levels of destabilization and higher premiums by maintaining guaranteed
issue while ending the individual mandate without any replacement
mechanism to promote enrollment of healthier individuals.
These and many additional issues are an unequivocal sign that we
must devise a better approach, rooted in a bi-partisan process in
Congress with input from States, consumers, and health-care providers.
graham-cassidy builds on a deeply flawed bill
Graham-Cassidy builds on and incorporates most of the provisions of
the Better Care Reconciliation Act (BCRA), which the Senate rejected
this summer. Although some provisions have been modified, Graham-
Cassidy largely adopts BCRA's general framework and, in particular, the
far-reaching changes it proposed to Medicaid--changes that go far
beyond repealing and replacing the Affordable Care Act. Like BCRA,
Graham-Cassidy would cut Federal Medicaid funding deeply and
fundamentally restructure Medicaid financing for the ``traditional''
(pre-expansion) Medicaid population. In addition, Graham-Cassidy takes
a step beyond BCRA by terminating not only the enhanced funding for the
Medicaid expansion but also the legal authority for States to cover
low-income parents and other adults even with regular matching
payments.\2\
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\2\ An exception is made for previously covered Native Americans
under certain circumstances.
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More specifically, Graham-Cassidy would:
Impose deep cuts to Medicaid that grow over time. While there is
no score yet for the Graham-Cassidy proposal, the Congressional Budget
Office (CBO) projected that the rejected BCRA bill upon which Graham-
Cassidy is based would have cut Medicaid by $756 billion over 10
years.\3\ The cuts grow over time as the trend rates used to make the
annual adjustments to the per-capita caps drop beginning in 2025.
Although Graham-Cassidy provides a modestly more generous trend rate
than BCRA, under both proposals, the deepest cuts occur just beyond the
CBO's 10-year budget scoring window.
---------------------------------------------------------------------------
\3\ Congressional Budget Office letter to the Honorable Mike Enzi
re: H.R. 1628, the Better Care Reconciliation Act of 2017: An Amendment
in the Nature of a Substitute [ERN17500], as posted on the website of
the Senate Committee on the Budget on July 20, 2017, available at:
https://www.cbo.gov/system/files/115th-congress-2017-2018/costestimate/
52941-hr1628bcra.
pdf.
---------------------------------------------------------------------------
Fundamentally change financing for most of the Medicaid program.
Graham-Cassidy would eliminate the Federal Government's guarantee to
share with States the cost of all qualifying Medicaid expenditures by
imposing per-capita caps on Federal spending for nearly all
populations. Since Graham-
Cassidy ends the Medicaid expansion, the consequences of this major
change in financing falls solely on those enrolled in the
``traditional'' Medicaid program: newborns and other children, very
low-income parents, pregnant women, and low-income seniors and people
with disabilities.
Shift all of the risk of higher costs onto States. Under the
proposal, States would bear the full risk of all costs that exceed the
trend rates, which are set below expected levels of health-care
spending in order to achieve Federal savings. By contrast, under
current law, States and the Federal Government share the risk of
unanticipated costs due, for example, to higher drug costs, new cancer
treatments, or health emergencies like the opioid crises. States that
are not able to shoulder significant new costs will need to reduce
provider payment rates and benefits, increase beneficiary costs, or
reduce eligibility.
marketplace health-care grants
The Graham-Cassidy proposal makes further structural changes to the
health coverage landscape--beyond BCRA--by ending the tax credits and
cost sharing subsidies available to people to purchase coverage in the
marketplace. In place of these subsidies and the funding for Medicaid
expansion, Graham-Cassidy establishes a ``Market-Based Health Care
Grant'' block grant. Like other block grants, the total amount of
Federal funding for this block grant is not adjusted overt time to
reflect changes in enrollment, use of services, or cost of care. In
addition, the block grant would be temporary; funding is available only
through 2026. States would be at full risk for any costs above the
block grant funding--should they take on the massive new
responsibilities that the Federal Government sends their way--and for
all costs when the block grant ends in 2026. There is no guarantee
whether and at what level Federal funding would be available beginning
in 2027.
Manatt Health analyzed the Graham-Cassidy proposal on behalf of the
Robert Wood Johnson Foundation's State Health and Value Strategies
Project.\4\ While there are various analyses estimating the impact of
the block grant component of the proposal, all estimates to date point
in the same direction: the majority of States will lose Federal funding
under Graham-Cassidy, with some experiencing particularly large losses.
---------------------------------------------------------------------------
\4\ We conducted two analyses. First we calculated unadjusted block
grant allotments based on the basic formulas in the bill to show the
State-by-State distribution of funding under the proposal. Given the
amount of discretion that is included in the proposal for the Secretary
of HHS to adjust the allotments, we also calculated illustrative State-
by-State allotments using a Medicare price index to adjust allotments
to account for differences in wages, input costs, and similar factors
that impact health care spending. While our assumptions are necessarily
uncertain, the analysis demonstrates that adjustments could result in
significant--and unknowable--changes to a State's allocation. ``Update:
State Policy and Budget Impacts of New Graham-Cassidy Repeal and
Replace Proposal'' (September 19, 2017), available at: http://
www.statenetwork.org/resource/update-state-policy-and-budget-impacts-
of-new-graham-cassidy-repeal-and-replace-proposal/.
---------------------------------------------------------------------------
Key takeaways from Manatt's analysis are noted here:
Total funding is below current law levels with much deeper cuts
for some States.
Over the 2020 to 2026 period, the block grant
would provide 6.4% less Federal funding than under current law with the
gap growing over time; in 2026, national funding for the block grant is
nearly 9 percent below current law spending projections.
The proposal radically alters the allocation of
funding relative to current law, leaving many States with very deep
cuts in funding. Over the 2020 to 2026 period, 29 States receive less
in Federal funding with an average reduction of 19 percent. Some States
will see their funding cut by half.
No State is a ``winner.''
The overall level of the block grant does not
adjust for actual costs or enrollment; some States may receive
adjustments in their allocations but at the expense of other States and
all States are at risk for costs over the capped.
Notably, these block grant allocations are in
addition to other deep funding reductions in the proposal.
The time-limited funding creates added risks for States. Under
the proposal, the block grant ends in 2026, leaving States to take on
substantial obligations with no guarantee of future funding.
States will be granted broad flexibility on how they use these
funds. The funds can be used for many purposes in addition to coverage,
and States will inevitably be faced with many competing pressures for
how to spend these funds. Individuals who have gained coverage through
Medicaid expansions and subsidized marketplace coverage have no
assurance that they will receive any coverage, never mind coverage that
is as affordable or comprehensive as that which is guaranteed under
current law.
implementation challenges
Beyond the precipitous drop in funding and the sweeping
programmatic changes advanced by this proposal, it is critical to
consider the enormity of the responsibilities that will be shifted to
States. States will have a very short time to consider how they will
proceed and to then actually implement changes to launch new coverage
and initiatives. It is no exaggeration to say that the Graham-Cassidy
proposal will result in chaos for our health-care system and most
notably for the millions of people who have coverage through Medicaid
and the marketplaces today.
______
attachment
Update: State Policy and Budget Impacts of New Graham-Cassidy Repeal
and Replace Proposal
Authored by Manatt Health
A grantee of the Robert Wood Johnson Foundation
September 2017
_______________________________________________________________________
IN THIS BRIEF
3 After 2019, the Graham-Cassidy proposal would eliminate federal
funding and authority for Medicaid expansion, as well as federal tax
credit and cost-sharing reduction subsidies for Marketplace coverage.
3 In 2020-2026, states instead would receive a block grant, referred
to as a
Market-Based Health Care allotment, which could be used for coverage,
payments to providers, or other purposes.
3 Over the 2020 to 2026 period, the block grant would provide 6.4
percent less federal funding than under current law. The size of the
gap between current law funding and the block grant appropriation would
be 8.9 percent by 2026.
3 Depending on the year, between 25 and 38 states would have
unadjusted allotments that provide less funding than under current law,
and some of these states would see reductions of 50 percent or more in
federal resources to support health coverage for low-income
individuals.
3 More than 23 million \1\ people are projected to have subsidized
coverage through Medicaid expansion or the Marketplace in 2019. Under
Graham-Cassidy, Medicaid expansion coverage and the federal
infrastructure for Marketplace subsidies would end, and states would
have full responsibility for addressing the health care needs of low-
income people without affordable coverage.
---------------------------------------------------------------------------
\1\ Table 1, page 4, https://www.cbo.gov/system/files/115th-
congress-2017-2018/reports/53091-fshic.pdf.
3 States would have broad latitude to obtain waivers of ACA
provisions, including waivers of ACA benefit and rating requirements.
In states that obtain waivers, individuals with pre-existing conditions
could face substantially higher premiums or find their policies do not
---------------------------------------------------------------------------
cover essential services.
3 States would have far more flexibility to decide how to deploy
federal resources, although the broad flexibility accompanying the new
Market-Based Health Care allotments could leave them vulnerable to
federal cuts in the future.
_______________________________________________________________________
Introduction
This brief provides an overview of the proposal released on September
13th by Senators Lindsey Graham (R-SC) and Bill Cassidy (R-LA)--along
with Senators Dean Heller (R-NV) and Ron Johnson (R-WI) and former
Senator Rick Santorum (R-PA)--to ``repeal and replace'' the Affordable
Care Act (ACA). This is an updated version of the proposal that
Senators Graham and Cassidy filed on July 27th. The Graham-Cassidy ACA
repeal and replace legislation would retain many features of the Better
Care Reconciliation Act (BCRA) voted down by the Senate on July 25th,
including per-capita caps on Medicaid spending \2\ and elimination of
the individual and employer mandates. However, it also goes beyond that
proposal by converting Marketplace and Medicaid expansion federal
funding into a block grant.
---------------------------------------------------------------------------
\2\ The new legislation changes the growth rate for elderly and
disabled in 2025 and beyond as compared to BCRA, and includes a delay
of the per-capita cap for certain rural states meeting specified
conditions.
---------------------------------------------------------------------------
OVERVIEW OF PROPOSAL
Graham-Cassidy would eliminate federal funding for Marketplace and
Medicaid expansion coverage after 2019 and replace it with a capped
allotment distributed to states in the form of ``Market-Based Health
Care'' block grants. The national amounts available for state
allotments would not vary based on actual costs or enrollment, and
would be less than estimated current law federal spending on
Marketplace and Medicaid expansion coverage. States would have
significant flexibility to use their block grant funds for coverage,
payments to providers, or other health care-related purposes. As
explained in the appendix and as illustrated by the state-by-state
estimates provided in Tables 1A, 1B and 2 of this analysis, the
proposal also alters the distribution of federal funds among states,
sending dollars from expansion states and other states that receive a
relatively significant share of current law federal subsidies for
Marketplace coverage to non-expansion states and those with lower
Marketplace participation and/or costs. No state match would be
required. The block grant would end after 2026.
For coverage funded with block grant dollars, states would be granted
waivers, upon request, of various federal rules governing coverage;
these include restrictions on premium variation, rating rules based on
health status, essential health benefit requirements, and minimum
medical loss ratios. While these provisions apply only to insurance
coverage funded under the allotment, by financing even a small coverage
program with allotment dollars, it appears a state could make the new
rules apply to the entire individual and small group markets.
Following is a summary of key issues and implications of the Graham-
Cassidy proposal for states, consumers, and other stakeholders.
Market-Based Health Care Grant Program--The Market-Based Health Care
Grant Program is the block grant that replaces federal funding for
Marketplace subsidies and Medicaid expansion coverage after 2019.
States would have significant flexibility to use their block grant
funds for coverage, payments to providers, or other health care-related
purposes. In 2020, the available block grant funds are distributed
among states based on their historic spending patterns for Marketplace,
Basic Health Program (BHP), and Medicaid expansion coverage. Over time,
however, the block grant formula increasingly distributes federal
dollars based on each state's share of low-income (between 45 percent
and 133 percent of the federal poverty level (FPL)) individuals
nationwide, adjusted to reflect the risk profile of the state's low-
income population, the actuarial value of coverage funded by the state
with block grant dollars, and a discretionary state-specific adjustment
by the Secretary of Health and Human Services (HHS). These adjustments
do not add any new dollars to the block grant, but can result in
changes in the distribution of block grant funds among states. In the
case of the Secretary's state-specific adjustment, the size of and
specifications for the adjustment are open-ended. In 2020 and 2021, an
additional contingency fund appropriation is available to increase
allotments for states with low population densities (Alaska, Montana,
North Dakota, South Dakota, and Wyoming) and those that did not expand
Medicaid under the ACA.
Manatt's estimates indicate the block grant program would provide a
lower level of funding at the national level relative to current law
and result in a substantial redistribution of the remaining resources
among states.\3\
---------------------------------------------------------------------------
\3\ Unless otherwise noted, the estimates presented here do not
reflect potential adjustments to the allotments of individual states
since it is unclear how they would be deployed by the Secretary of HHS
and cannot be used to increase the national funding level available for
state allotments.
Over 2020 to 2026, the block grant would provide states
with $81.6 billion less in federal funding than would be available
under current law, a reduction of 6.4 percent. In 2026, national
funding for the block grant is 8.9 percent below current law spending
---------------------------------------------------------------------------
projections.
Most states would receive less funding under the block
grant than under current law. As shown in Table 1A, 32 states would
receive less federal funding in 2020 under the unadjusted amount of the
block grant. By 2026, some states fare better, but the majority (27
states) continue to face a loss of federal funding. Over the 2020 to
2026 period, 29 states receive less in federal funding with an average
reduction of 19 percent.
In some states, the loss of federal funding is
significantly higher, reflecting the disparate impact of the Graham-
Cassidy proposal on states that have expanded Medicaid and/or generally
have higher-cost care. States such as Alaska, Connecticut, Delaware,
New Hampshire, New Mexico, New York, Oregon, Vermont, and Washington
would see reductions of 25 percent or more over the 2020 to 2026 period
under the Graham-Cassidy unadjusted allotments relative to current law.
Over 2020 to 2026, 22 states would receive more federal
funding under their unadjusted block grant amount than under current
law, although they still would face cuts as a result of the Medicaid
per-capita cap included in the Graham-
Cassidy proposal.\4\ This group of states is dominated by non-expansion
states, but also includes some expansion states with relatively low
Medicaid and/or Marketplace expenditures per person.
---------------------------------------------------------------------------
\4\ Although not shown here, our earlier analysis indicated that
the per-capita cap included in BCRA, the earlier Senate legislation to
repeal and replace the Affordable Care Act that was voted down by the
Senate on July 25th, would result in an $189.2 billion reduction in
federal Medicaid expenditures between fiscal year 2020 and fiscal year
2026. We will be updating these estimates to reflect interactions
between Graham-Cassidy's modified version of the BCRA per-capita cap in
the near future.
Allowable adjustments to the block grant amounts could
result in significant changes in the distribution of federal resources
among states. For example, if the Secretary elects to take the
geographic cost of providing services into account using a Medicare
price index, 33 states see a decrease in their 2020 to 2026 federal
funding from the adjustment while the remaining states see an increase.
This is because the Secretary can only increase funding for higher cost
states by reducing the federal funding available for lower cost states.
With the price adjustment, the number of states receiving less 2020 to
---------------------------------------------------------------------------
2026 federal funding relative to current law increases from 29 to 31.
See Table 1A for estimates of state-by-state federal funding for
unadjusted allotments under the Market-Based Health Care Grant Program.
To illustrate the potential impact of the adjustments, Table 1B
provides illustrative estimates that assume the Secretary of HHS
adjusts each state's allotment to reflect a state-specific measure of
the cost of providing care. Table 2 provides additional detail on
current law federal expenditures for Marketplace, BHP, and Medicaid
expansion coverage.
State Responsibility for Coverage--More than 23 million \5\ people are
projected to have subsidized coverage through the Medicaid expansion or
Marketplace in 2019. Under Graham-Cassidy, Medicaid expansion coverage
and the federal infrastructure for Marketplace subsidies would end, and
as of January 1, 2020, states would assume full responsibility for
addressing health-care needs for low-income individuals who do not have
affordable insurance. The block grant, however, provides states with
less funding to do so as compared to current law funding levels.
---------------------------------------------------------------------------
\5\ https://www.cbo.gov/system/files/115th-congress-2017-2018/
reports/53091-fshic.pdf.
Graham-Cassidy would provide new state flexibility,
including to repurpose federal dollars away from coverage to payments
to providers or other health care-related initiatives. However, the
lack of a clear connection to coverage and minimal federal requirements
---------------------------------------------------------------------------
may put the funding at greater risk for reductions in the future.
In addition to determining how best to use block grant
funds to address lack of coverage, stabilize the market and reduce
premiums and other out-of-pocket costs, state policymakers may face
pressure to use some of these funds to address state budget issues,
heightened by other components of the bill, including the per-capita
cap on federal Medicaid payments \6\ and the bill's restriction on
states' use of provider taxes and assessments.\7\
---------------------------------------------------------------------------
\6\ As noted, the Graham-Cassidy proposal would impose per person
caps on federal funding for almost all Medicaid populations, including
children, seniors, and people with disabilities and on virtually all
services, including acute care, preventive care, and nursing home and
other long-term care services. The trend rates for the caps tighten
considerably in 2025; they are set at the medical CPI for the elderly
and disabled populations and at CPI for all other beneficiaries. While
the trend rate for elderly and disabled enrollees is more generous than
was provided under BCRA, these trend rates are below CBO projections
for the growth of health care and long-term care costs.
\7\ Graham-Cassidy tightens the proposal first advanced in BCRA to
reduce states' ability to rely on provider taxes and assessments to
finance Medicaid or other State priorities. The constraints begin in
2021 and by 2025, the current 6 percent limit that guides CMS in
determining what is and is not an acceptable tax is reduced to 4
percent. See HR1628, section 123.
States will be at full financial risk for funding
coverage programs and services developed under the block grant when the
grant ends in 2026; there is no guarantee of whether and at what level
---------------------------------------------------------------------------
federal funding would be available beginning in 2027.
Waiver Authority and Effects on Individuals with Pre-Existing
Conditions--The proposal gives states broad latitude to obtain waivers
(under new authority) of the ACA's consumer protection and insurance
regulation provisions for individual or small group coverage funded
through the Market-Based Health Care Grant Program. States would have
the flexibility to eliminate the essential health benefit or any other
benefit rule; allow insurers to vary premiums based on health, age, or
any factor other than sex or membership in a protected class; and
eliminate requirements for a minimum medical loss ratio. In states that
obtain waivers, individuals with pre-existing conditions could face
substantially higher premiums in the individual and small group
markets, or find their policies do not cover essential services. While
coverage must be available on a guaranteed-issue basis, states could
obtain waivers to permit insurers to increase premiums or contributions
based on health status, or carve out or limit coverage for the specific
treatments they need. Unlike under the ACA's Section 1332 waivers,
there are no coverage ``guardrails'' limiting the waivers. Instead,
states must describe in their waiver applications how individuals with
pre-existing conditions will have ``adequate'' and ``affordable''
coverage.
Implications for Individual Market/Marketplace Coverage--The proposal
eliminates the individual and employer mandates, the premium tax credit
and cost-sharing subsidies, and permits a broader range of individuals
to purchase catastrophic coverage, but leaves many of the other current
law (ACA) requirements for individual market and Marketplace plans in
place unless a state seeks a waiver. Without state action, premiums in
this market would likely increase substantially, potentially
destabilizing the market.
Other Key Medicaid Provisions--As noted, Graham-Cassidy not only
establishes the Market-Based Health Care allotments, but also
permanently terminates the state option to expand Medicaid; beginning
in 2020, states would no longer have the option to cover expansion
populations, even at the regular match (with the exception of
grandfathered Native American populations, under certain
circumstances). In addition, it converts Medicaid funding to a per-
capita cap (although the current draft includes a more favorable trend
rate for elderly and disabled populations than earlier versions of
Senate repeal and replace legislation and for frontier states with low
Market-Based Health Care allotments, the proposed legislation delays
implementation of the per-capita cap). States with allotments that
grow, relative to a base year, by less than the medical component of
the Consumer Price Index (CPI) would be eligible for a proportionate
reduction in their otherwise applicable Medicaid disproportionate share
hospital (DSH) cuts, but would need to provide the non-federal share to
draw down these dollars. However, Graham-Cassidy no longer delays
pending Medicaid DSH reductions for non-expansion states (or states
that drop their expansion), meaning that all states will experience DSH
reductions in federal fiscal year (FFY) 2018. Both hospitals and states
also will see an impact from the bill's provision that restricts
states' abilities to rely on provider taxes, phasing down the allowable
tax safe harbor from 6 percent to 4 percent in FFY 2025 and beyond.
Graham-Cassidy also modifies longstanding Medicaid retroactive
eligibility authority for most Medicaid beneficiaries to provide only
two (not three) months of coverage; three months of retroactive
coverage would continue to be available for recipients who are 65 or
older and who are eligible for Medicaid on the basis of being blind or
disabled at the time the application is made. Finally, the legislation
no longer includes an earlier BCRA provision that appropriated $45
billion for substance use disorder treatment and recovery services,
plus $252 million for research.
CONCLUSION
The Graham-Cassidy proposal would have major implications for states
and their residents given the smaller pool of federal funding that
would be available for coverage as compared to funding under current
law, the redistribution of the reduced federal funds among states, the
major restructuring of federal financing for state Medicaid programs
overall, and the ability for states to waive key consumer protections
of the ACA. Particularly in the long term, given that national amounts
for the new block grants would be indexed at a rate below general
inflation and then terminated after 2026, coupled with the
establishment of per-capita caps for all non-
expansion populations in the Medicaid program, the legislation could
create significant fiscal and political pressure on state policymakers.
Finally, the proposal provides states with significant flexibility to
determine how to use their federal block grant dollars, but it also
provides the Secretary of HHS with substantial flexibility to decide
how to distribute federal block grant funds among states.
Table 1A. Estimated Federal Spending for Marketplace and Medicaid Expansion Under Current Law Versus Unadjusted Allotments PUnder Graham-Cassidy, 2020-2026 (millions)
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Marketplace, BHP, and Medicaid expansion under Graham-Cassidy unadjusted allotment \2\
current law \1\ -------------------------------------------------------------------------------------------------------
State ---------------------------------------------------- Amount Change relative to current law
-------------------------------------------------------------------------------------------------------
2020 2021 2026 2020-2026 2020 2021 2026 2020-2026 2020 2021 2026 2020-2026
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
United States....................... $155,932 $164,363 $208,636 $1,268,550 $152,000 $151,000 $190,000 $1,187,000 $(3,932) $(13,363) $(18,636) $(81,550)
Alabama............................. $1,481 $1,550 $1,802 $11,493 $1,284 $1,601 $3,564 $16,842 $(197) $51 $1,762 $5,349
Alaska.............................. $579 $610 $767 $4,694 $928 $772 $281 $3,534 $349 $162 $(486) $(1,160)
Arizona............................. $4,201 $4,469 $5,972 $35,315 $4,106 $4,041 $4,936 $31,619 $(95) $(428) $(1,036) $(3,696)
Arkansas............................ $1,709 $1,803 $2,337 $14,060 $1,737 $1,734 $2,246 $13,938 $28 $(69) $(91) $(122)
California.......................... $26,390 $27,812 $35,486 $215,291 $25,688 $24,233 $24,263 $174,185 $(702) $(3,579) $(11,223) $(41,106)
Colorado............................ $2,454 $2,589 $3,328 $20,117 $2,437 $2,317 $2,418 $16,939 $(17) $(272) $(910) $(3,178)
Connecticut......................... $2,085 $2,198 $2,806 $17,025 $2,026 $1,844 $1,486 $12,213 $(59) $(354) $(1,320) $(4,812)
Delaware............................ $777 $820 $1,058 $6,381 $780 $696 $483 $4,383 $3 $(124) $(575) $(1,998)
District of Columbia................ $380 $402 $530 $3,159 $406 $385 $395 $2,792 $26 $(17) $(135) $(367)
Florida............................. $10,211 $10,660 $12,357 $78,868 $8,902 $9,258 $14,188 $79,040 $(1,309) $(1,402) $1,831 $172
Georgia............................. $2,730 $2,850 $3,302 $21,082 $2,380 $3,047 $7,056 $32,834 $(350) $197 $3,754 $11,752
Hawaii.............................. $654 $690 $897 $5,387 $670 $627 $604 $4,441 $16 $(63) $(293) $(946)
Idaho............................... $549 $573 $663 $4,237 $479 $544 $1,024 $5,187 $(70) $(29) $361 $950
Illinois............................ $4,580 $4,824 $6,086 $37,154 $4,328 $4,440 $6,334 $37,368 $(252) $(384) $248 $214
Indiana............................. $2,703 $2,848 $3,665 $22,136 $2,707 $2,834 $4,324 $24,662 $4 $(14) $659 $2,526
Iowa................................ $872 $919 $1,164 $7,091 $828 $892 $1,482 $8,111 $(44) $(27) $318 $1,020
Kansas.............................. $553 $579 $671 $4,289 $479 $688 $1,851 $8,153 $(74) $109 $1,180 $3,864
Kentucky............................ $4,023 $4,247 $5,564 $33,293 $4,200 $3,897 $3,560 $27,025 $177 $(350) $(2,004) $(6,268)
Louisiana........................... $2,624 $2,763 $3,493 $21,296 $2,500 $2,543 $3,526 $21,111 $(124) $(220) $33 $(185)
Maine............................... $489 $512 $594 $3,793 $423 $468 $835 $4,333 $(66) $(44) $241 $540
Maryland............................ $2,228 $2,347 $2,992 $18,156 $2,174 $2,132 $2,565 $16,568 $(54) $(215) $(427) $(1,588)
Massachusetts....................... $2,935 $3,087 $3,948 $23,908 $2,906 $2,820 $3,241 $21,474 $(29) $(267) $(707) $(2,434)
Michigan............................ $5,629 $5,934 $7,640 $46,134 $5,623 $5,289 $5,214 $37,779 $(6) $(645) $(2,426) $(8,355)
Minnesota........................... $2,533 $2,674 $3,462 $20,855 $2,588 $2,416 $2,284 $16,975 $55 $(258) $(1,178) $(3,880)
Mississippi......................... $507 $529 $614 $3,916 $442 $803 $2,661 $10,942 $(65) $274 $2,047 $7,026
Missouri............................ $1,501 $1,571 $1,824 $11,640 $1,301 $1,473 $2,758 $14,007 $(200) $(98) $934 $2,367
Montana............................. $1,022 $1,077 $1,362 $8,303 $1,669 $1,416 $613 $6,747 $647 $339 $(749) $(1,556)
Nebraska............................ $679 $712 $829 $5,288 $586 $621 $999 $5,435 $(93) $(91) $170 $147
Nevada.............................. $1,526 $1,623 $2,171 $12,834 $1,515 $1,498 $1,864 $11,820 $(11) $(125) $(307) $(1,014)
New Hampshire....................... $541 $570 $730 $4,421 $530 $491 $441 $3,381 $(11) $(79) $(289) $(1,040)
New Jersey.......................... $5,020 $5,290 $6,768 $41,002 $4,937 $4,654 $4,643 $33,405 $(83) $(636) $(2,125) $(7,597)
New Mexico.......................... $2,109 $2,227 $2,918 $17,460 $2,199 $1,986 $1,520 $12,920 $90 $(241) $(1,398) $(4,540)
New York............................ $17,024 $18,194 $25,537 $147,102 $17,151 $15,487 $11,833 $100,712 $127 $(2,707) $(13,704) $(46,390)
North Carolina...................... $4,917 $5,148 $5,986 $38,183 $4,256 $4,403 $6,653 $37,323 $(661) $(745) $667 $(860)
North Dakota........................ $280 $296 $374 $2,280 $460 $445 $382 $2,641 $180 $149 $8 $361
Ohio................................ $5,054 $5,331 $6,913 $41,587 $5,140 $5,135 $6,658 $41,290 $86 $(196) $(255) $(297)
Oklahoma............................ $1,252 $1,312 $1,527 $9,739 $1,081 $1,315 $2,812 $13,506 $(171) $3 $1,285 $3,767
Oregon.............................. $4,317 $4,562 $6,011 $35,824 $4,403 $3,834 $2,145 $22,668 $86 $(728) $(3,866) $(13,156)
Pennsylvania........................ $6,067 $6,389 $8,043 $49,157 $5,699 $5,527 $6,330 $42,028 $(368) $(862) $(1,713) $(7,129)
Rhode Island........................ $520 $548 $703 $4,250 $519 $499 $546 $3,718 $(1) $(49) $(157) $(532)
South Carolina...................... $1,434 $1,499 $1,743 $11,112 $1,245 $1,468 $2,972 $14,597 $(189) $(31) $1,229 $3,485
South Dakota........................ $216 $226 $264 $1,680 $302 $362 $508 $2,658 $86 $136 $244 $978
Tennessee........................... $1,825 $1,912 $2,224 $14,189 $1,576 $1,976 $4,433 $20,883 $(249) $64 $2,209 $6,694
Texas............................... $5,688 $5,944 $6,898 $44,016 $4,946 $6,835 $17,530 $78,513 $(742) $891 $10,632 $34,497
Utah................................ $739 $772 $895 $5,714 $642 $757 $1,536 $7,539 $(97) $(15) $641 $1,825
Vermont............................. $526 $555 $709 $4,297 $518 $462 $319 $2,905 $(8) $(93) $(390) $(1,392)
Virginia............................ $1,982 $2,071 $2,402 $15,329 $1,725 $2,022 $4,051 $19,983 $(257) $(49) $1,649 $4,654
Washington.......................... $4,861 $5,140 $6,822 $40,481 $5,010 $4,527 $3,476 $29,486 $149 $(613) $(3,346) $(10,995)
West Virginia....................... $1,326 $1,399 $1,806 $10,893 $1,331 $1,265 $1,318 $9,244 $5 $(134) $(488) $(1,649)
Wisconsin........................... $1,427 $1,494 $1,734 $11,071 $1,956 $1,942 $2,590 $15,475 $529 $448 $856 $4,404
Wyoming............................. $203 $212 $245 $1,568 $284 $279 $252 $1,668 $81 $67 $7 $100
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Source: Manatt Health analysis.
Notes: Amounts assume that the entire 2020 allotment amount of $146 billion is distributed to states, including the $10 billion reserve fund. In addition, amounts shown here include $6 billion
in 2020 and $5 billion in 2021 to increase allotments for low-density (AK, MT, ND, SD, WY) and non-expansion states.
\1\ Amounts are for federal fiscal years. See Table 2 for additional detail.
\2\ Estimates assume that states will choose 2017 as their base year for use in allotment calculations. As a result, amounts differ from those provided on Senator Cassidy's website (https://
www.cassidy.senate.gov/read-about-graham-cassidy-heller-johnson), which use 2016 as the base year.
Table 1B. Estimated Federal Spending for Marketplace and Medicaid Expansion Under Current Law Versus Adjusted Allotments Under Graham-Cassidy, 2020-2026 (millions)
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Marketplace, BHP, and Medicaid expansion under Graham-Cassidy allotment with illustrative price adjustment \2\
current law \1\ -------------------------------------------------------------------------------------------------------
State ---------------------------------------------------- Amount Change relative to current law
-------------------------------------------------------------------------------------------------------
2020 2021 2026 2020-2026 2020 2021 2026 2020-2026 2020 2021 2026 2020-2026
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
United States....................... $155,932 $164,363 $208,636 $1,268,550 $152,000 $151,000 $190,000 $1,187,000 $(3,932) $(13,363) $(18,636) $(81,550)
Alabama............................. $1,481 $1,550 $1,802 $11,493 $1,284 $1,361 $3,059 $14,523 $(197) $(189) $1,257 $3,030
Alaska.............................. $579 $610 $767 $4,694 $928 $863 $345 $4,013 $349 $253 $(422) $(681)
Arizona............................. $4,201 $4,469 $5,972 $35,315 $4,106 $3,901 $4,902 $31,092 $(95) $(568) $(1,070) $(4,223)
Arkansas............................ $1,709 $1,803 $2,337 $14,060 $1,737 $1,486 $1,979 $12,359 $28 $(317) $(358) $(1,701)
California.......................... $26,390 $27,812 $35,486 $215,291 $25,688 $27,581 $28,409 $197,306 $(702) $(231) $(7,077) $(17,985)
Colorado............................ $2,454 $2,589 $3,328 $20,117 $2,437 $2,223 $2,386 $16,563 $(17) $(366) $(942) $(3,554)
Connecticut......................... $2,085 $2,198 $2,806 $17,025 $2,026 $2,007 $1,664 $13,276 $(59) $(191) $(1,142) $(3,749)
Delaware............................ $777 $820 $1,058 $6,381 $780 $689 $492 $4,400 $3 $(131) $(566) $(1,981)
District of Columbia................ $380 $402 $530 $3,159 $406 $417 $440 $3,032 $26 $15 $(90) $(127)
Florida............................. $10,211 $10,660 $12,357 $78,868 $8,902 $8,526 $13,322 $74,073 $(1,309) $(2,134) $965 $(4,795)
Georgia............................. $2,730 $2,850 $3,302 $21,082 $2,380 $2,748 $6,472 $30,054 $(350) $(102) $3,170 $8,972
Hawaii.............................. $654 $690 $897 $5,387 $670 $696 $690 $4,917 $16 $(6) $(207) $(470)
Idaho............................... $549 $573 $663 $4,237 $479 $505 $972 $4,901 $(70) $(68) $309 $664
Illinois............................ $4,580 $4,824 $6,086 $37,154 $4,328 $4,246 $6,232 $36,448 $(252) $(578) $146 $(706)
Indiana............................. $2,703 $2,848 $3,665 $22,136 $2,707 $2,594 $4,071 $23,140 $4 $(254) $406 $1,004
Iowa................................ $872 $919 $1,164 $7,091 $828 $831 $1,421 $7,732 $(44) $(88) $257 $641
Kansas.............................. $553 $579 $671 $4,289 $479 $619 $1,692 $7,432 $(74) $40 $1,021 $3,143
Kentucky............................ $4,023 $4,247 $5,564 $33,293 $4,200 $3,447 $3,239 $24,690 $177 $(800) $(2,325) $(8,603)
Louisiana........................... $2,624 $2,763 $3,493 $21,296 $2,500 $2,206 $3,146 $18,905 $(124) $(557) $(347) $(2,391)
Maine............................... $489 $512 $594 $3,793 $423 $451 $824 $4,240 $(66) $(61) $230 $447
Maryland............................ $2,228 $2,347 $2,992 $18,156 $2,174 $2,376 $2,940 $18,471 $(54) $29 $(52) $315
Massachusetts....................... $2,935 $3,087 $3,948 $23,908 $2,906 $3,100 $3,665 $23,641 $(29) $13 $(283) $(267)
Michigan............................ $5,629 $5,934 $7,640 $46,134 $5,623 $5,044 $5,116 $36,765 $6 $(890) $(2,524) $(9,369)
Minnesota........................... $2,533 $2,674 $3,462 $20,855 $2,588 $2,428 $2,361 $17,268 $55 $(246) $(1,101) $(3,587)
Mississippi......................... $507 $529 $614 $3,916 $442 $695 $2,331 $9,563 $(65) $166 $1,717 $5,647
Missouri............................ $1,501 $1,571 $1,824 $11,640 $1,301 $1,339 $2,552 $12,943 $(200) $(232) $728 $1,303
Montana............................. $1,022 $1,077 $1,362 $8,303 $1,669 $1,382 $605 $6,629 $647 $305 $(757) $(1,674)
Nebraska............................ $679 $712 $829 $5,288 $586 $585 $963 $5,208 $(93) $(127) $134 $(80)
Nevada.............................. $1,526 $1,623 $2,171 $12,834 $1,515 $1,512 $1,935 $12,080 $(11) $(111) $(236) $(754)
New Hampshire....................... $541 $570 $730 $4,421 $530 $498 $460 $3,466 $(11) $(72) $(270) $(955)
New Jersey.......................... $5,020 $5,290 $6,768 $41,002 $4,937 $4,939 $5,068 $35,610 $(83) $(351) $(1,700) $(5,392)
New Mexico.......................... $2,109 $2,227 $2,918 $17,460 $2,199 $1,911 $1,505 $12,667 $90 $(316) $(1,413) $(4,793)
New York............................ $17,024 $18,194 $25,537 $147,102 $17,151 $17,080 $13,426 $110,645 $127 $(1,114) $(12,111) $(36,457)
North Carolina...................... $4,917 $5,148 $5,986 $38,183 $4,256 $4,070 $6,272 $35,101 $(661) $(1,078) $286 $(3,082)
North Dakota........................ $280 $296 $374 $2,280 $460 $427 $367 $2,538 $180 $131 $(7) $258
Ohio................................ $5,054 $5,331 $6,913 $41,587 $5,140 $4,706 $6,277 $38,809 $86 $(625) $(636) $(2,778)
Oklahoma............................ $1,252 $1,312 $1,527 $9,739 $1,081 $1,164 $2,525 $12,136 $(171) $(148) $998 $2,397
Oregon.............................. $4,317 $4,562 $6,011 $35,824 $4,403 $3,926 $2,260 $23,358 $86 $(636) $(3,751) $(12,466)
Pennsylvania........................ $6,067 $6,389 $8,043 $49,157 $5,699 $5,313 $6,260 $41,177 $(368) $(1,076) $(1,783) $(7,980)
Rhode Island........................ $520 $548 $703 $4,250 $519 $521 $586 $3,913 $(1) $(27) $(117) $(337)
South Carolina...................... $1,434 $1,499 $1,743 $11,112 $1,245 $1,324 $2,727 $13,381 $(189) $(175) $984 $2,269
South Dakota........................ $216 $226 $264 $1,680 $302 $352 $497 $2,590 $86 $126 $233 $910
Tennessee........................... $1,825 $1,912 $2,224 $14,189 $1,576 $1,716 $3,897 $18,400 $(249) $(196) $1,673 $4,211
Texas............................... $5,688 $5,944 $6,898 $44,016 $4,946 $6,255 $16,346 $72,913 $(742) $311 $9,448 $28,897
Utah................................ $739 $772 $895 $5,714 $642 $701 $1,451 $7,092 $(97) $(71) $556 $1,378
Vermont............................. $526 $555 $709 $4,297 $518 $482 $343 $3,045 $(8) $(73) $(366) $(1,252)
Virginia............................ $1,982 $2,071 $2,402 $15,329 $1,725 $1,884 $3,853 $18,920 $(257) $(187) $1,451 $3,591
Washington.......................... $4,861 $5,140 $6,822 $40,481 $5,010 $4,600 $3,634 $30,246 $149 $(540) $(3,188) $(10,235)
West Virginia....................... $1,326 $1,399 $1,806 $10,893 $1,331 $1,134 $1,215 $8,532 $5 $(265) $(591) $(2,361)
Wisconsin........................... $1,427 $1,494 $1,734 $11,071 $1,956 $1,862 $2,544 $15,084 $529 $368 $810 $4,013
Wyoming............................. $203 $212 $245 $1,568 $284 $282 $264 $1,714 $81 $70 $19 $146
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Source: Manatt Health analysis.
Notes: Amounts assume that the entire 2020 allotment amount of $146 billion is distributed to states, including the $10 billion reserve fund. In addition, amounts shown here include $6
billion in 2020 and $5 billion in 2021 to increase allotments for low-density (AK, MT, ND, SD, WY) and non-expansion states.
\1\ Amounts are for federal fiscal years. See Table 2 for additional detail.
\2\ The Graham-Cassidy proposal includes state-level allotment adjustments for population risk, actuarial value of coverage, and, at the Secretary of HHS's discretion, state-specific factors
(e.g., wage rates). For illustrative purposes, amounts shown here include a state-specific adjustment based on a price index constructed using actual and standardized Medicare costs per
capita for 2015 (https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Medicare-Geographic-Variation/GV_PUF.html).
Table 2. Detail on Estimated Federal Spending for Marketplace and Medicaid Expansion Coverage PUnder Current Law, 2020-2026 (millions)
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
2020 2021 2026 2020-2026
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State Marketplace \1\ Medicaid Marketplace \1\ Medicaid Marketplace \1\ Medicaid Marketplace \1\ Medicaid
and BHP \2\ expansion \3\ Total and BHP \2\ expansion \3\ Total and BHP \2\ expansion \3\ Total and BHP \2\ expansion \3\ Total
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
United States....................................... $69,910 $86,022 $155,932 $73,396 $90,967 $164,363 $87,672 $120,964 $208,636 $550,477 $718,073 $1,268,550
Alabama............................................. $1,481 $- $1,481 $1,550 $- $1,550 $1,802 $- $1,802 $11,493 $- $11,493
Alaska.............................................. $242 $337 $579 $254 $356 $610 $296 $471 $767 $1,888 $2,806 $4,694
Arizona............................................. $1,201 $3,000 $4,201 $1,262 $3,207 $4,469 $1,471 $4,501 $5,972 $9,382 $25,933 $35,315
Arkansas............................................ $293 $1,416 $1,709 $306 $1,497 $1,803 $356 $1,981 $2,337 $2,269 $11,791 $14,060
California.......................................... $7,990 $18,400 $26,390 $8,369 $19,443 $27,812 $9,739 $25,747 $35,486 $62,104 $153,187 $215,291
Colorado............................................ $585 $1,869 $2,454 $614 $1,975 $2,589 $714 $2,614 $3,328 $4,559 $15,558 $20,117
Connecticut......................................... $636 $1,449 $2,085 $667 $1,531 $2,198 $779 $2,027 $2,806 $4,960 $12,065 $17,025
Delaware............................................ $162 $615 $777 $170 $650 $820 $197 $861 $1,058 $1,259 $5,122 $6,381
District of Columbia................................ $4 $376 $380 $4 $398 $402 $4 $526 $530 $28 $3,131 $3,159
Florida............................................. $10,211 $- $10,211 $10,660 $- $10,660 $12,357 $- $12,357 $78,868 $- $78,868
Georgia............................................. $2,730 $- $2,730 $2,850 $- $2,850 $3,302 $- $3,302 $21,082 $- $21,082
Hawaii.............................................. $98 $556 $654 $102 $588 $690 $119 $778 $897 $757 $4,630 $5,387
Idaho............................................... $549 $- $549 $573 $- $573 $663 $- $663 $4,237 $- $4,237
Illinois............................................ $1,785 $2,795 $4,580 $1,871 $2,953 $4,824 $2,177 $3,909 $6,086 $13,887 $23,267 $37,154
Indiana............................................. $593 $2,110 $2,703 $619 $2,229 $2,848 $715 $2,950 $3,665 $4,573 $17,563 $22,136
Iowa................................................ $328 $544 $872 $344 $575 $919 $403 $761 $1,164 $2,561 $4,530 $7,091
Kansas.............................................. $553 $- $553 $579 $- $579 $671 $- $671 $4,289 $- $4,289
Kentucky............................................ $335 $3,688 $4,023 $350 $3,897 $4,247 $406 $5,158 $5,564 $2,591 $30,702 $33,293
Louisiana........................................... $970 $1,654 $2,624 $1,015 $1,748 $2,763 $1,180 $2,313 $3,493 $7,525 $13,771 $21,296
Maine............................................... $489 $- $489 $512 $- $512 $594 $- $594 $3,793 $- $3,793
Maryland............................................ $668 $1,560 $2,228 $698 $1,649 $2,347 $810 $2,182 $2,992 $5,168 $12,988 $18,156
Massachusetts....................................... $776 $2,159 $2,935 $806 $2,281 $3,087 $929 $3,019 $3,948 $5,935 $17,973 $23,908
Michigan............................................ $1,269 $4,360 $5,629 $1,327 $4,607 $5,934 $1,542 $6,098 $7,640 $9,836 $36,298 $46,134
Minnesota........................................... $915 $1,618 $2,533 $965 $1,709 $2,674 $1,200 $2,262 $3,462 $7,389 $13,466 $20,855
Mississippi......................................... $507 $- $507 $529 $- $529 $614 $- $614 $3,916 $- $3,916
Missouri............................................ $1,501 $- $1,501 $1,571 $- $1,571 $1,824 $- $1,824 $11,640 $- $11,640
Montana............................................. $375 $647 $1,022 $393 $684 $1,077 $457 $905 $1,362 $2,917 $5,386 $8,303
Nebraska............................................ $679 $- $679 $712 $- $712 $829 $- $829 $5,288 $- $5,288
Nevada.............................................. $372 $1,154 $1,526 $389 $1,234 $1,623 $450 $1,721 $2,171 $2,877 $9,957 $12,834
New Hampshire....................................... $155 $386 $541 $162 $408 $570 $190 $540 $730 $1,205 $3,216 $4,421
New Jersey.......................................... $1,373 $3,647 $5,020 $1,436 $3,854 $5,290 $1,668 $5,100 $6,768 $10,641 $30,361 $41,002
New Mexico.......................................... $185 $1,924 $2,109 $194 $2,033 $2,227 $227 $2,691 $2,918 $1,442 $16,018 $17,460
New York............................................ $4,978 $12,046 $17,024 $5,466 $12,728 $18,194 $8,691 $16,846 $25,537 $46,825 $100,277 $147,102
North Carolina...................................... $4,917 $- $4,917 $5,148 $- $5,148 $5,986 $- $5,986 $38,183 $- $38,183
North Dakota........................................ $99 $181 $280 $104 $192 $296 $120 $254 $374 $769 $1,511 $2,280
Ohio................................................ $847 $4,207 $5,054 $886 $4,445 $5,331 $1,030 $5,883 $6,913 $6,567 $35,020 $41,587
Oklahoma............................................ $1,252 $- $1,252 $1,312 $- $1,312 $1,527 $- $1,527 $9,739 $- $9,739
Oregon.............................................. $674 $3,643 $4,317 $707 $3,855 $4,562 $824 $5,187 $6,011 $5,253 $30,571 $35,824
Pennsylvania........................................ $2,472 $3,595 $6,067 $2,591 $3,798 $6,389 $3,016 $5,027 $8,043 $19,233 $29,924 $49,157
Rhode Island........................................ $120 $400 $520 $125 $423 $548 $143 $560 $703 $918 $3,332 $4,250
South Carolina...................................... $1,434 $- $1,434 $1,499 $- $1,499 $1,743 $- $1,743 $11,112 $- $11,112
South Dakota........................................ $216 $- $216 $226 $- $226 $264 $- $264 $1,680 $- $1,680
Tennessee........................................... $1,825 $- $1,825 $1,912 $- $1,912 $2,224 $- $2,224 $14,189 $- $14,189
Texas............................................... $5,688 $- $5,688 $5,944 $- $5,944 $6,898 $- $6,898 $44,016 $- $44,016
Utah................................................ $739 $- $739 $772 $- $772 $895 $- $895 $5,714 $- $5,714
Vermont............................................. $140 $386 $526 $147 $408 $555 $169 $540 $709 $1,084 $3,213 $4,297
Virginia............................................ $1,982 $- $1,982 $2,071 $- $2,071 $2,402 $- $2,402 $15,329 $- $15,329
Washington.......................................... $613 $4,248 $4,861 $640 $4,500 $5,140 $741 $6,081 $6,822 $4,734 $35,747 $40,481
West Virginia....................................... $274 $1,052 $1,326 $287 $1,112 $1,399 $335 $1,471 $1,806 $2,134 $8,759 $10,893
Wisconsin........................................... $1,427 $- $1,427 $1,494 $- $1,494 $1,734 $- $1,734 $11,071 $- $11,071
Wyoming............................................. $203 $- $203 $212 $- $212 $245 $- $245 $1,568 $- $1,568
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Source: Manatt Health analysis.
Notes: Amounts are for federal fiscal years.
\1\ Reflects national growth as projected by CBO, applied to state-level amounts. Estimate based on:
2017 tax credit data for all states (https://downloads.cms.gov/files/effectuated-enrollment-snapshot-report-06-12-17.pdf);
2016 cost-sharing reduction (CSR) data for 38 HealthCare.gov states (https://aspe.hhs.gov/health-insurance-marketplace-cost-sharing-reduction-subsidies-zip-code-and-county-2016), with national average applied to CSR enrollees in
remaining states (https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Marketplace-Products/Effectuated_QuarterlyP_Snapshots.html);
September 2017 CBO projections for national totals (https://www.cbo.gov/system/files/115th-congress-2017-2018/reports/53091-fshic.pdf). Because CBO recently revised its projections, current law estimates shown here differ from a
previous publication describing an earlier version of the Graham-Cassidy proposal (http://www.statenetwork.org/wp-content/uploads/2017/08/SHVS_Repeal-and-Replace_Final.pdf).
\2\ MN and NY provide BHP coverage for certain individuals who would otherwise be eligible for subsidies through the Marketplace. Estimates of federal funding reflect projections in state budget documents, with amounts extended out
to 2026 using 2021 growth rate (https://mn.gov/dhs/general-public/publications-forms-resources/reports/financial-reports-and-forecasts.jsp; https://www.budget.ny.gov/pubs/archive/fy18archive/enactedfy18/FY2018EnactedFP.pdf).
\3\ Estimate based on Manatt Medicaid Financing Model for background, see (http://www.statenetwork.org/resource/understanding-the-senates-better-care-reconciliation-act-of-2017-bcra-key-implications-for-medicaid/). Note that the
national figure differs from CBO baseline for ACA subsidies (https://www.cbo.gov/sites/default/files/recurringdata/51298-2017-01-healthinsurance.pdf) in part because CBO: (1) only breaks out federal spending on Medicaid expansion
for individuals who were made eligible by the ACA; (2) assumes that additional states have expanded by 2020. Spending from the Manatt Medicaid Financing Model includes newly eligible individuals in the expansion adult group but
also those who were eligible under pre-ACA rules, for whom states may receive enhanced federal match (AZ, DE, HI, MA, MN, NY, VT, WA) and/or regular federal match (AR, CO, CT, IL, IN, IA, MI, NH, NY, ND, OH, OR, PA; in all but IN,
NY, and OR the estimated share of expansion group enrollees at regular match is less than 10 percent).
Appendix: Additional Details on the Market-based Health Care Grant
Program
National Funding Levels
2020: $146 billion (with $10 billion out of 2020
appropriation reserved for an increase in 2020 allotments of up to 5
percent for each state, with any unspent amount added to 2026
allotments)
2021: $146 billion
2022: $157 billion
2023: $168 billion
2024: $179 billion
2025: $190 billion
2026: $190 billion
2027 and beyond: No allocation
In addition, in 2020 and 2021, a ``contingency fund'' of $6 billion and
$5 billion, respectively, is available for states with fewer than 15
residents per square mile (25 percent) and non-expansion states (75
percent).
Uses of Funds
Allowable uses of funds include:
Stabilizing premiums and promoting issuer participation in the
individual market;
Paying providers directly for health-care services;
Funding assistance to reduce out-of-pocket costs for people in
the individual market;
Helping people buy coverage, including by paying individual
market premiums; and
Providing health insurance coverage for Medicaid-eligible
individuals by establishing and maintaining relationships with health
insurance issuers, but limited to 15 percent of the state's allotments.
Funds can be used for up to 2 years after the year for
which they were appropriated (e.g., 2020 funds could be used in 2020,
2021, and 2022).
No state matching requirement.
State-specific allotments are prorated as needed to match
the national allotments.
Distribution Formula
The formula for distributing funds among states changes over time. In
2020 it is based on a state's historic spending on Medicaid expansion,
Marketplace coverage, and the BHP, indexed forward from a base period.
Over time, allotments increasingly are based on a state's share of low-
income individuals between 45 percent and 133 percent of the FPL.
Beginning in 2021, state allotments also may be adjusted based on the
risk profile of the state's low-income population, the actuarial value
of coverage funded by the state with block grant dollars, and a
discretionary state-specific adjustment by the Secretary of HHS that
accounts for additional factors (e.g., wage rates) that impact health-
care expenditures in a state.
2020 Allotment
Based on the following sum of federal expenditures in a
state during a base period (selected by a state from four consecutive
quarters between first quarter of fiscal year 2014 and first quarter of
2018):
Medicaid expansion, indexed by MACPAC projections through
November 2019;
BHP, indexed by medical CPI;
Advanced premium tax credits, indexed by medical CPI; and
Cost-sharing reductions, indexed by medical CPI.
In 2020, states may request a share of up to $10 billion
that is reserved for an advance payment to increase their 2020
allotments.
2021 to 2025 Allotments
During this period, each state's allotment is based on its
prior year allotment taking into account special adjustments (see
below) plus or minus one-sixth of the difference between the state's
prior year allotment and its projected 2026 allotment. (As described
below, the 2026 allotment is based on each state's share of low-
income people.)
The following adjustments may be applied to a state's
allotment, depending on the year and state circumstances:
Population risk adjustment
A risk adjustment factor based on the clinical risk
categories into which the low-income individuals in each state are
classified in accordance with a methodology to be developed by the
Secretary
Applies to 2021 to 2026, but phased in between 2021
(25 percent), 2022 (50 percent), 2023 (75 percent)
In all years, limited to increasing/decreasing a
state's allotment by no more than 10 percent
Coverage value adjustment
Applies to 2024, 2025, and 2026, but phased in at 25
percent in 2024, 50 percent in 2025, and 75 percent in 2026
Reduces a state's allotment in proportion to the
extent to which it offers coverage valued at less than the amount
required for targeted low-income children in the Children's Health
Insurance Program (CHIP)
The proposal provides specific rules for how to
``value'' the coverage of selected individuals (e.g., individuals
served by the block grant who are not receiving any coverage must be
assigned an actuarial value of 0 percent)
State-specific population adjustment
Secretary's discretion to adjust allotments according
to a ``population adjustment factor''
Must take into account ``legitimate factors'' that
impact health expenditures beyond clinical characteristics of low-
income individuals
May include demographics, wage rates, income levels,
and other factors
2026 Allotment
In 2026, each state receives a share of the available
national allotment ($190 billion) based on its share of low-income
individuals between 45 percent and 133 percent of FPL.
The adjustments described above under the formula for 2021
to 2025 continue to apply in 2026.
______
Questions Submitted for the Record to Cindy Mann
Questions Submitted by Hon. Robert Menendez
Question. Families who have children with special needs often face
an uphill battle in accessing services. What protections does the
Graham-Cassidy-Heller-Johnson bill offer them to ensure their children
are not cut off from care for their conditions? That a young child
isn't forced to go without care because they have hit an annual cap? A
lifetime cap?
Answer. Graham-Cassidy would cap Federal Medicaid spending
beginning in fiscal year 2020. Even though spending for a few
populations--including children eligible for Medicaid based on
disability--is exempt from the per-capita cap, the proposal creates an
aggregate cap on Federal spending that is computed based on those caps.
That aggregate cap is what sets the limit on Federal spending on the
program, constraining spending in the Medicaid program, not just for
the populations subject to the per-capita cap. For this reason the caps
will have ramifications across the program and impact even those
populations that the legislation appears to protect. In order to keep
funding under the aggregate cap, States may be forced to reduce
provider rates or optional benefits, potentially jeopardizing care for
children with disabilities. States might seek to reduce spending by
reducing or eliminating eligibility for high cost enrollees, which
could put high-needs children covered under optional Medicaid
eligibility groups at risk.
In addition, Graham-Cassidy would allow States to adjust the scope
of Essential Health Benefits to people who receive care on the
individual market. This could mean that coverage could be less robust,
with the scope of benefits reduced relative to current laws. Before the
ACA was enacted, Medicaid often picked up the costs for high needs kids
who hit the private insurance benefits caps. Graham-Cassidy introduces
the possibility that such need could arise again, but in a capped
funding environment, there would be less Federal financial support for
Medicaid to meet this important need.
Question. Wrap-around services are of critical importance to many
families who have children with disabilities and who earn too much to
qualify for Medicaid. How will Senator Cassidy's proposal ensure these
families don't lose access to critically important services for their
children and family members?
Answer. Graham-Cassidy does not protect wrap-around services for
children with disabilities and their families and in fact jeopardizes
the continued availability of these critical services. Even though
children eligible based on disability are not subject to the per-capita
cap under the proposal, the computations based on the per-capita caps
build up to an aggregate cap, and the aggregate cap will drive
programmatic cuts that will ripple across the Medicaid program. Through
funding reductions and caps, the proposal puts coverage at risk for
virtually every group of individuals covered through ``traditional''
Medicaid, including one out of three children in the Nation as well as
millions of elderly people and both adults and children with
disabilities whose long term care services are covered by Medicaid. In
addition, some services that children with disabilities rely upon--
including home and community based services--are optional Medicaid
services and could be cut in an environment in which States are seeking
to manage their programs to ensure they do not exceed capped
allotments.
Question. If States use the Market-Based Health Care Block Grant to
establish high-risk pools, do you think there is sufficient funding in
the grants to ensure States are able to operate the pool in a manner
that will cover as many people as are currently covered under the
Affordable Care Act?
Answer. No. Graham-Cassidy would eliminate Federal funding for
Marketplace and Medicaid expansion coverage after 2019 and replace it
with a capped allotment distributed to States in the form of ``Market-
Based Health Care'' block grants. The block grant ends in 2026, leaving
States with no funding to continue block grant initiatives, unless the
program is reauthorized. The national amounts available from 2020-2026
for State allotments would not vary based on actual costs or enrollment
and would be less than estimated current law Federal spending on
Marketplace and Medicaid expansion coverage. As such, there is not
sufficient funding in the grants to cover the same number of people
with the same or similar scope of benefits as are covered today.
Furthermore, under Graham-Cassidy, States would have flexibility to use
their block grants for many purposes, including but not limited to
coverage; there will be many competing demands for these dollars. A
State that chose to use some of its block grant funds to establish a
high risk pool would have even less funding to provide comprehensive
coverage for those losing Medicaid and Marketplace coverage. At the
same time, given competing demands, States would likely find funding
insufficient to meet needs in such a high risk pool, which are
typically designed to serve sicker and more expensive patients.
medicaid expansion
Question. The legislation introduced by Senators Bill Cassidy,
Lindsay Graham, Dean Heller, and Ron Johnson (Graham-Cassidy-Heller-
Johnson) proposes to make radical changes to Medicaid beginning in
2020. First, the bill would impose per-capita caps on the traditional
program, which covers over 60 million low-income children, pregnant
women, seniors, and individuals with disabilities. Second, the bill
would eliminate the Affordable Care Act's (ACA) optional Medicaid
expansion, which today covers over 11 million low-income adults across
31 States and the District of Columbia.
While these proposals echo the caps proposed by Senate Republicans
earlier this summer, Graham-Cassidy's proposed changes to Medicaid
expansion would be more severe than any proposal introduced thus far.
This is because Graham-Cassidy ends both the Federal match for Medicaid
expenditures under the program as well as the Medicaid expansion
eligibility pathway. As a result, in 2020, all individuals covered
under the Medicaid expansion would lose their coverage.
During the September 25th hearing before the U.S. Senate Finance
Committee, there was confusion created over what happens to the
Medicaid expansion program and its beneficiaries under the Graham-
Cassidy bill. For example, when Senator Heller asked Senator Cassidy,
``Could an expanded State like Nevada use the money to replicate their
current Medicaid expansion system?'' Senator Cassidy responded with:
``Absolutely.'' Could you please clarify whether States would be
permitted to continue providing Medicaid coverage to the expansion
population under Graham-Cassidy as they do today? Is it correct that
this eligibility pathway is terminated in 2020 for expansion States and
as of September 1, 2017 for non-expansion States? Is it correct that a
State would no longer be eligible for enhanced Federal funding under
the expansion FMAP?
Answer. States like Nevada could not replicate their current
Medicaid expansion system under the Cassidy-Graham legislation. They
could not maintain their Medicaid expansion because the Graham-Cassidy
legislation eliminates the eligibility pathway that allows States the
flexibility to expand--upon enactment for States that haven't yet
expanded and in 2020, for States that have already expanded. This means
that States could not receive even the regular Federal match to cover
the Medicaid expansion population. While some States might pursue 1115
waivers to retain Medicaid coverage for expansion populations, Federal
budget neutrality rules could make it very difficult--if not
impossible--to continue coverage for expansion adults.
Although the block grant funding could be used by States to
establish alternative coverage programs, the Congressional Budget
Office's (CBO's) preliminary analysis of the Graham-Cassidy legislation
still concludes that ``millions'' would lose coverage under the
proposed legislation. In particular, CBO indicates that by 2026, the
amount of block grant funding received by expansion States would be
enough to cover only a population that is similar in size and cost to
its current law Medicaid expansion population. In other words, there
would be no Federal funding available to serve those who would have had
Marketplace coverage under current law. While States could choose to
use their block grant funds to subsidize a population that differs from
the expansion group, the end result is the same--millions of people
losing coverage.\1\
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\1\ Congressional Budget Office, ``Preliminary Analysis of
Legislation That Would Replace Subsidies for Health Care With Block
Grants,'' September 2017, available at: https://www.cbo.gov/
publication/53126. CBO based its analysis on Version LYN17744 of the
proposed legislation, available here: https://www.cassidy.senate.gov/
imo/media/doc/LYN177444.pdf.
Question. Even if States attempted to replicate their previous
expansion coverage with block grant funds and ignored other competing
demands for the dollars, the block grant is no replacement for
Medicaid. The total amount of Federal funding available to States does
not adjust based on enrollment or costs as it does under Medicaid; and
to keep the cost of coverage from exceeding the block grant funds,
States would likely impose enrollment caps and potentially waiting
lists. In addition, the block grant ends in 2026, leaving States with
no funding to continue block grant initiatives--including replacement
coverage for the Medicaid expansion population--unless the program is
reauthorized. The expiration of the funding not only jeopardizes
coverage post 2026 but will make States understandably reluctant to
take on substantial coverage responsibilities for fear of ``holding the
---------------------------------------------------------------------------
bag'' once the block grant funds expire.
There was also confusion created around whether States who have
expanded their Medicaid programs would receive more or fewer Federal
dollars than under current law. Senator Cassidy claimed that some
expansion States would benefit from the block grant because they would
no longer be required to provide a 10-percent State match to receive
Federal expansion funding. For example, Senator Heller claimed that
without this 10-percent match, Nevada would save $1.16 billion. Can you
please explain, briefly, whether States that picked up the Medicaid
expansion would receive more or fewer Federal dollars to assist low-
income residents with health insurance coverage under the Graham-
Cassidy proposal? In your view, would States that have not expanded
receive more Federal support than they would have otherwise had access
to if they choose to expand their Medicaid programs?
Answer. Over time, nearly all States that expanded Medicaid will
receive fewer Federal dollars under Graham-Cassidy than they would
under current law. While Senator Heller is correct that the 10-percent
State match that the State will provide to draw down Federal Medicaid
matching funds to support the Medicaid expansion would no longer be
required, all but a handful of expansion States would receive far less
Federal support under Graham-Cassidy than they do today and would have
to spend more--not less--to maintain coverage at current levels.
In general, Manatt's analysis of the September 13th version of the
Graham-
Cassidy legislation indicates that States that expanded Medicaid would
receive fewer Federal dollars to assist low-income residents with
health insurance coverage. For example, according to Manatt's analysis
of the September 13th legislation, Nevada stands to lose as much as a
billion dollars, relative to current law.\2\ However, there were
subsequent adjustments to the legislation that would benefit specific
States (including Nevada), through an expansion of the low-density
definition, the addition of contingency funds for expansion States, and
targeted increases for other States, which could reduce this loss to
some extent.\3\
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\2\ ``Update: State Policy and Budget Impacts of the New Graham-
Cassidy Repeal and Replace Proposal,'' prepared by Manatt Health for
the Robert Wood Johnson Foundation, State Health and Value Strategies,
September 2017, available at: http://www.statenetwork.org/wp-content/
uploads/2017/09/SHVS_Graham-Cassidy-Sept-2017_Final.pdf.
\3\ The September 25th updated version of the legislation also
would allot 5 percent of Short Term Assistance funds to low-density
States, like Nevada, with fewer than 30 people per square mile
(previously defined as those with fewer than 15 people per square
mile).
There is no basis for saying that non-expansion States would
categorically receive more Federal funding under the block grant than
if they expanded under current law. First, the block grant is capped
nationwide and is not adjusted based on the actual cost of care or the
number of people who might enroll. By contrast, if a State expands
coverage under Medicaid it is guaranteed Federal dollars to cover no
less than 90 percent of the cost of care for all eligible people who
enroll. If costs rise due to an epidemic like the opioid crisis, or
because of rising drug costs, or if enrollment grows due to a recession
or a natural disaster that puts people out of work, under current law
Medicaid funding will adjust but the total block grant funds would not.
Second, even if a given State does not experience higher costs or
enrollment, another State might, and Graham-Cassidy allows the
Secretary to increase one State's allocation at the expense of another
---------------------------------------------------------------------------
State. That too undermines any certainty for States.
In addition, an added danger for individuals who might have been
eligible for Medicaid under an expansion is that the Market-Based
Health Care Grants can be used for any number of initiatives, meaning
that although the funds could be available to help support coverage for
the Medicaid population, it is just as likely that the funding would be
used to cover the costs of coverage for individuals at higher income
levels.
______
Question Submitted by Hon. Ron Wyden
medicaid per-capita caps
Question. Beginning in 2020, the Graham-Cassidy proposal would
convert the open-ended structure of the traditional Medicaid program to
a per-capita cap system, where Federal reimbursements for Medicaid
expenditures are capped at a set amount per beneficiary.
Proposals like Graham-Cassidy to cap Medicaid would dramatically
reduce Federal funding for the program, especially over the long-term,
forcing States to compensate for shortfalls by limiting Medicaid
enrollment, eliminating optional benefits, and reducing payments to
providers. Thus, Medicaid per-capita caps risk beneficiaries' access to
needed benefits as well as the quality of Medicaid-funded services.
During the September 25th hearing before the U.S. Senate Finance
Committee, in an exchange concerning Medicaid in Kansas, Senator Pat
Roberts asked Senator Cassidy whether it was ``fair to say the Kansas
cap is in fact higher than what they currently spend?'' In response,
Senator Cassidy said, ``Yes, you can spend, you can also supplement, if
you will, the traditional Medicaid budget with the extra dollars that
Kansas is receiving, and you have the flexibility to do that as well.''
Could you please clarify whether States like Kansas will face
reductions in Federal support under the per-capita cap proposed by
Graham-Cassidy? Would such a cap take into account economic factors
like a recession or local down-turn, costs of new medical treatments
like new drugs, or demographic factors like an aging baby boomer
population?
Answer. All States--including Kansas--could receive a reduction in
Federal support under the per-capita cap proposed by Graham-Cassidy.
This is because the per-capita cap limits most Medicaid spending to
growth rates that are below national averages projected for Medicaid
spending. Because, on average, the rate of growth in the per-capita cap
trend rates would not keep pace with actual expenditure growth that
would occur under current law, as confirmed by CBO's analyses, the
Graham-Cassidy Medicaid per-capita caps could result in reduced Federal
support for States. Kansas's experience is instructive. Even though
Kansas's per capita spending between 2000 and 2011 grew more slowly
than spending in many other States, Kansas's spending for the aged,
children, and adults grew more rapidly than CPI and also outstripped
medical CPI for children and adults.\4\ Furthermore, while Federal
funding under the caps would adjust for enrollment increases during a
recession or local down-turn, the caps would not provide any allowance
for increased costs associated with new medical treatments, health
emergencies like the opioid crisis, or demographic factors like an
aging baby boomer population. It is difficult to predict with certainty
the level of added costs that will arise due to these types of
occurrences, but there is no question that such costs will arise. This
is the fundamental challenge of a per-capita cap that uses a one-size-
fits all, predetermined trend rate to set future spending levels and
does not adjust to reflect variations in spending triggered by factors
well beyond a State's control.
---------------------------------------------------------------------------
\4\ ``Medicaid Capped Funding: Findings and Implications for
Kansas,'' Robert Wood Johnson Foundation, State Health Reform
Assistance Network (April 5, 2017), available at: http://
www.statenetwork.org/wp-content/uploads/2017/04/KS-Fact-Sheet_rev-
4.4.17-1.pdf.
______
Questions Submitted by Hon. Bill Nelson
Question. Eleven seniors in Florida died after being trapped in a
nursing home in extreme temperatures after Hurricane Irma knocked out
the facility's power. Most troubling is that there was a functioning
hospital located directly across the street from the nursing home, and
yet they weren't evacuated. There's an ongoing criminal investigation
to determine what went wrong and who is to blame, but quite simply,
this isn't acceptable.
Nursing homes and other long-term care facilities are under
tremendous pressure to provide quality care and take care of our loved
ones, but they need the resources in order to do so.
The Graham-Cassidy bill caps Medicaid, effectively cutting billions
from the program. The cap would grow more slowly each year than the
projected growth in State per-beneficiary costs, especially over time
with an aging population. The cuts to Federal Medicaid funding would
only deepen in 2025 as the annual adjustment becomes even more
inadequate.
This is especially problematic for Florida as the rate of Medicaid
enrollment for disabled persons and low-income seniors has risen faster
than the national average over the last 10 years.
Moreover, the cap would force States to make hard choices about
cutting eligibility, benefits, and/or provider payments. Many States
will be faced with no choice but to cut-home and community-based
services, and other ``optional'' benefits.
Do you believe the Graham-Cassidy bill would allow nursing homes,
home health agencies, and other long-term care facilities to provide
quality care to the Nation's seniors?
Answer. The bill would put quality care for seniors at significant
risk. Over time, the per-capita caps would result in Federal payments
that increasingly fall short of need, driving hard decisions for States
about cutting benefits, eligibility, or provider rates, including for
nursing homes and home care. Long term care services account for nearly
30 percent of Medicaid costs;\5\ if long term care could be protected
it could only be done at the expense of medical services for the
elderly, for people with disabilities, children and pregnant women--or
with significant new State funding. The fact that the trend rate for
aged/disabled populations is less constraining than the rate applied to
other populations under Graham-Cassidy does not protect these
populations for two reasons. First, at least based on Florida's recent
past, the trend rates proposed in the legislation for the elderly fall
short of need. Between 2000 and 2011, Florida's average annual per
enrollee spending growth was 7.3 percent for the aged, significantly
outstripping CPI (2.5 percent) and medical CPI (4 percent) during that
period, suggesting that a per-capita cap pegged at medical CPI or
medical CPI plus one would fall short of need.\6\
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\5\ Steve Eiken, Kate Sredl, Brian Burwell, and Rebecca Woodward,
``Medicaid Expenditures for Long-Term Services and Supports (LTSS) in
fiscal year 2015,'' Figure 7 (Truven Health Analytics, April 14, 2017),
available at: https://www.medicaid.gov/medicaid/ltss/downloads/reports-
and-evaluations/ltssexpendituresffy2015final.pdf.
\6\ ``Medicaid Capped Funding: Findings and Implications for
Florida,'' Robert Wood Johnson Foundation, State Health Reform
Assistance Network (April 5, 2017), available at http://
www.statenetwork.org/wp-content/uploads/2017/04/FL-Fact-Sheet-revised-
4.4.17-1.pdf.
Second, because the per-capita caps build up to an aggregate cap,
the elderly will not be protected from cuts even if their per enrollee
costs are below the caps. If there is extra ``room'' for some
populations it will be used to finance coverage for other populations
for whom the caps will squeeze more deeply. States will manage their
budgets under the aggregate caps and the elderly will be as vulnerable
under the aggregate cap as other groups. As State budgets are
increasingly squeezed, States could reduce reimbursement for nursing
homes and other long-term care facilities, thus jeopardizing the
quality of care the beneficiaries receive. In addition, since most home
care services are optional, States may end up dropping those services
(or create new or longer waiting lists under home and community based
services waivers). While home care services are a cost effective
alternative to nursing home care for seniors who do not need to be
served in a nursing home, home care for someone who needs extensive
help with activities of daily living is still costly and may be at risk
---------------------------------------------------------------------------
in a capped funding environment.
It is also important to note that while States will generally turn
to eligibility reductions last under a per-capita cap, the caps provide
a perverse incentive to end optional eligibility for the most high
need, high cost patients. The elderly and people with disabilities who
rely on Medicaid for their long-term care are often covered under
optional eligibility categories and their relatively high cost will no
doubt prompt States to consider whether they can continue to afford to
maintain this coverage.
Question. Twenty-five percent of Florida's population or 5 million
Floridians are 60 or older, making Florida the State with the largest
population of seniors. Generally older adults have more health-care
needs, chronic conditions and co-morbidities than younger people. Many
older Americans are also forced to tighten their belts to afford things
like health coverage.
Please tell me with a ``yes'' or ``no'' answer, does the Graham-
Cassidy bill repeal the ACA's premium tax credits?
Answer. Yes.
Question. Does the Graham-Cassidy bill eliminate cost-sharing
reduction payments?
Answer. The Graham-Cassidy bill repeals the Federal Cost-Sharing
Reduction (CSR) payments after 2019. Until then, it does not explicitly
appropriate funds for the CSR payments.
Question. Does the Graham-Cassidy bill allow States to take us back
to the days when insurers could charge older adults higher rates than
under the existing law?
Answer. Yes. Although the September 25th version of Graham-Cassidy
puts more restrictions on States' ability to change rating laws than
previous versions, the revised legislation still permits States to seek
HHS permission to vary otherwise applicable rules in order to offer
coverage that does not meet all Federal requirements. States therefore
could seek authority to let insurers vary premiums based on factors
such as age. States also would have discretion to allow rating rules
that increase premiums for people with preexisting conditions, a
provision that would impact older adults. In addition, although the
newer version appears to facially prohibit premium rating based on
health, it expressly allows ``multiple risk pools'' which could open
the door to discrimination based on health status if States allow
insurers to put people with preexisting conditions in separate risk
pools where all premiums will be higher than standard rates. This
change could result in a return to pre-ACA practices, where people with
minor health issues may be required to pay higher rates than would be
actuarially justified for their particular condition because they are
identified as having a preexisting condition and made ineligible for
the standard risk pool. Individuals placed in an expensive plan under
these circumstances might also find themselves without recourse, since
plan underwriting decisions are discretionary and generally not subject
to as much State review as rating decisions. In addition to expressly
allowing multiple risk pools, the September 25th version of the
legislation also allows States to override Federal rules establishing
out of pocket limits and actuarial value requirements, essentially
removing many meaningful protections for the quality of coverage.
Question. The opioid crisis is devastating families across the
country. In Florida alone, 2,600 people died from opioids in the first
half of 2016. Fentanyl was responsible for 704 of those deaths.
The Affordable Care Act made great strides to increase access to
substance abuse treatment. It ensured that newly covered individuals
would receive mental health and substance use disorder services,
including behavioral health treatment, under their health insurance
plan as part of their essential health benefits.
Is substance use disorder treatment a necessary component of
efforts to prevent and treat opioid addiction?
Answer. There are many strategies to combat the opioid epidemic and
substance use disorder treatment is certainly a necessary component.
Preventing addiction is important, of course, but so too is ensuring
that States have the infrastructure and resources to treat individuals
with opioid addiction.
Question. Does the Graham-Cassidy bill allow States to waive
essential health benefits, like coverage of mental health and substance
use disorder services?
Answer. As most recently revised on September 25th, Graham-Cassidy
give States broad latitude to obtain HHS approval to implement
``alternative rules'' that would override the ACA's consumer protection
and insurance regulation provisions for individual or small group
coverage funded through the Market-Based Grant Program. Therefore, by
implementing alternative rules, States presumably could receive
approval to either eliminate or modify Essential Health Benefits.
Therefore, this provision puts coverage for mental health and substance
use disorder services in jeopardy.
Question. By capping the Medicaid program and ending Medicaid
expansion, the Graham-Cassidy bill cuts billions of dollars from
Medicaid, the largest payer of substance use services in the country. A
September 25th CBO report stated that the Graham-Cassidy bill cuts $1
trillion out of Medicaid over 10 years. If those cuts are made, how do
you propose States like Florida provide the necessary services to help
individuals with substance use disorders?
Answer. States would have several options, none of which would
provide funding at the levels available today and all of which would
likely force tradeoffs against funding for other key services. States
like Florida could devote a higher share of State dollars to support
substance use disorder services, they could pursue limited Substance
Abuse and Mental Health Services Administration Federal grant funds, or
they could use their Market Based Health Care block grant to finance
treatment of substance use disorders either as a stand-alone benefit or
as part of coverage funded by the block grant. Either approach to using
block grant funds would mean that the State would have to make
difficult tradeoffs in light of the limited funding available under the
Graham-Cassidy block grant. For example, investing more in substance
use disorder treatment and prevention would necessarily crowd out other
services and initiatives, which would jeopardize the State's ability to
maintain coverage at current levels. Or, even if States spent all of
their block grant funds on coverage for people who could be eligible
for the Medicaid expansion or who are currently enrolled in Marketplace
coverage, nationally the funding would not be sufficient to cover both
populations or to ensure that funding includes full scope mental health
or SUD treatment. And, if States like Florida used funding just for SUD
treatment, people experiencing SUD but who have other, often related,
medical and behavioral health-care needs wouldn't receive the treatment
they need to restore or maintain their health.
Your question also raises a little-appreciated challenge associated
with the
Market-Based Health Care Grants. In addition to determining how best to
use block grant funds to address lack of coverage, stabilize the
market, and reduce premiums and other out-of-pocket costs, State
policymakers could use block grant funds to supplant current State
funding as long as it was health related. The pressure may be strong
for a State to use some of these funds to address State budget issues,
particularly because other components of the bill, including the per-
capita cap on Federal Medicaid payments and the bill's restriction on
States' use of provider taxes and assessments will create significant
new budget pressures for States. The competing demand for the block
grant dollars will crowd out or at least substantially limit States'
ability to address the opioid epidemic.
Question. Some have said that the public health emergency response
fund could be used for the opioid epidemic; however, it is my
understanding that this money was for disasters like Hurricane Irma.
Does that mean flood victims and those suffering from opioid addiction
will be pitted against each other?
Answer. Unfortunately, the very nature of capped programs is that
funding is limited so, yes, relying on the public health emergency
response fund to finance a response to the opioid epidemic would very
likely crowd out disaster response spending.
Question. Ms. Mann, if Florida expanded its Medicaid program,
wouldn't it be able to increase access to treatment for those with
opioid use disorders? And wouldn't expanding Medicaid help States avoid
the rising costs associated with the opioid crisis better than what was
proposed in the Graham-Cassidy bill?
Answer. Yes, under current law, if Florida expands its Medicaid
program to adults up to 138 percent of poverty, it could vastly expand
access to treatment for those with opioid use disorder. And it could do
so with a 90 percent Federal match going forward, meaning that with a
10 percent State contribution the State could draw down significant
Federal support to help cover low-income adults in Medicaid.\7\
---------------------------------------------------------------------------
\7\ ``Medicaid's Role in Addressing the Opioid Epidemic,'' Kaiser
Family Foundation (September 2017), available at: https://www.kff.org/
infographic/medicaids-role-in-addressing-opioid-epidemic/.
The comprehensive Medicaid benefit available to beneficiaries
provides coverage for substance use treatment as well as behavioral
health and other issues that could drive addiction. By comparison,
there is no guarantee that coverage under Graham-Cassidy would provide
either a comprehensive benefit package or effective, targeted coverage
for the types of services most helpful in combatting the opioid
---------------------------------------------------------------------------
epidemic.
Question. Ms. Mann, how would Florida fair under this bill as
compared to if the State had expanded Medicaid as is currently an
option under the existing law?
Answer. Manatt's quantitative analysis suggests that Florida could
fare worse under Graham-Cassidy than if the State expanded Medicaid
under current law with the Medicaid expansion funding and Marketplace
subsidies remaining intact. For example, Manatt's analysis projects
that Florida residents will receive $10.2 billion in Federal
Marketplace funds in 2020 to support coverage for individuals from 100
percent to 400 percent of poverty.\8\ If Florida expanded Medicaid up
to 138 percent of poverty, Manatt estimates that the State would
receive a net increase in Federal funding of $1 billion or more in
2020, as previously uninsured individuals gain Medicaid coverage and
Marketplace enrollees between 100 percent and 138 percent FPL shift to
Medicaid.\9\ Thus, Florida's combined Marketplace and Medicaid
expansion Federal funding would exceed $11 billion in 2020 and to
remain ``whole'' under
Graham-Cassidy relative to current law, in 2020 the State would need a
Market-Based Health Care allotment of at least $11 billion. (This does
not account for any additional funding Florida might need due to
unanticipated costs which Medicaid would cover but which would not be
accommodated by the block grant.) According to our analysis of the
September 13th version of the legislation, Florida's unadjusted
allotment was expected to be only $8.9 billion in 2020; this is less
than the State could expect to receive if current law remained intact
and the State expanded Medicaid. In addition, if block grants were
adjusted to reflect each State's health care prices relative to the
national average (as allowed at the option of the Administrator of the
Centers for Medicare and Medicaid Services in 2023 and beyond under the
September 25th version of the proposal), our analysis finds that
Florida could see a 5-percent reduction in its block grant amount,
further lowering the Federal funding available under Graham-Cassidy-
Heller relative to current law.
---------------------------------------------------------------------------
\8\ See August 2017 Manatt analysis of a July 27th version of
Graham-Cassidy at https://www.statenetwork.org/wp-content/uploads/2017/
08/SHVS_Repeal-and-Replace_Final.pdf.
\9\ See August 2017 Manatt analysis of a July 27th version of
Graham-Cassidy at https://www.statenetwork.org/wp-content/uploads/2017/
08/SHVS_Repeal-and-Replace_Final.pdf. Note that a later Manatt analysis
of the September 13th version of Graham-Cassidy contained somewhat
lower Marketplace spending estimates due to a downward revision of
national projections issued by the Congressional Budget Office in
September. See: ``Update: State Policy and Budget Impacts of the New
Graham-Cassidy Repeal and Replace Proposal,'' prepared by Manatt Health
for the Robert Wood Johnson Foundation, State Health and Value
Strategies (September 2017), available at: http://www.statenetwork.org/
wp-content/uploads/2017/09/SHVS_Graham-Cassidy-Sept-2017_Final.pdf.
Question. The Graham-Cassidy bill repeals the Affordable Care Act's
Medicaid expansion, premium tax credits, and cost-sharing reduction
---------------------------------------------------------------------------
payments and instead creates a block grant.
It is my understanding that the block grant funding ends after 2026
under the Graham-Cassidy bill. What happens to the individual
marketplace after 2026?
Answer. It is difficult, if not impossible, to predict what will
happen in the individual marketplace after 2026 when the block grant
funds expire. Without Federal funding for tax credits or other
subsidies to help make coverage affordable, even if a State continued
to offer coverage, it is likely that most people will be priced out of
the market. The block grant funds could be renewed but whether and at
what level they might be renewed is highly speculative particularly
given the cost of renewal. To take a current example of this type of
uncertainty, as of November 15th, the CHIP block grant, which is much
smaller, and highly popular has yet to be renewed.
Question. Would you say that gutting the current individual
marketplace by changing it to a block grant from 2020 to 2026, and
creating a funding cliff after 2026 is good for the stability of the
individual insurance market? Insurers are already having trouble
setting their 2018 rates because the administration won't commit to
funding the CSRs. How do you expect them to plan for 2027?
Answer. Graham-Cassidy is not good for the long-term stability of
the individual insurance market, and it will be impossible for insurers
to plan for 2027. To take just one example, because Graham-Cassidy
eliminates the individual mandate, to the extent that States continue
to offer coverage it is likely that the risk pool will be skewed
because more sick people will be motivated to purchase coverage than
healthy people, making coverage difficult for insurers to price and
prohibitively expensive for consumers. The funding cliff will add
significantly to the uncertainty for insurers as well as States.
Question. I'm the former Florida insurance commissioner, and I've
seen what can help stabilize an insurance marketplace. That's why I,
with my friend from across the aisle, Senator Collins, have introduced
the Lower Premiums Through Reinsurance Act to help States establish
their own reinsurance programs. Do you think this bill is a good
solution to help stabilize the ACA's individual market?
Answer. The legislation you introduced with Senator Collins, the
Lower Premiums Through Reinsurance Act, is part of a good solution to
stabilize the ACA's individual market. Reinsurance programs help
promote marketplace stability by reducing premiums by separately
financing the most expensive cases, increasing insurer participation by
removing outlier costs that make it harder to set adequate premiums,
and enhancing market stability by spreading the most volatile costs
across a broader funding base. Coupled with your legislation, another
key step to stabilize the market is for Congress to act to fund cost
sharing reductions as well.
Question. Medicaid is the largest health-care program for children,
covering more than 30 million kids. As it is currently structured, the
Medicaid program gives States flexibility to innovate and pursue
delivery system reforms. How will States be able to transform care and
pursue delivery system reforms to improve child health outcomes if the
Medicaid program is gutted under either a cap or block grant?
Answer. Delivery system reform efforts would be challenging in a
per-capita cap or block grant environment. Delivery system reform
efforts often require investments in order to drive change; in a capped
funding environment, States will be less likely--or able--to make such
investments as they strive to maintain eligibility, services, and
access to providers for their enrolled population, especially over time
as the caps tighten. In addition, actions States may have to take to
keep spending below the caps could compromise the care children
receive; this is likely to be particularly the case for children with
disabilities or chronic illnesses. Reductions in provider payment rates
could limit access to specialists and make it more difficult to support
integrated delivery systems and a strong continuum of care for children
with special needs. Furthermore, with the loss of the expansion,
millions of parents will lose coverage and that too affects children's
coverage and well-being.
______
Questions Submitted by Hon. Sherrod Brown
intellectual and developmental disabilities population
Question. The Graham-Cassidy proposal includes a provision that
seems to try and protect children with intellectual or developmental
disabilities who are on Medicaid by exempting those receiving
Supplemental Security Income, or SSI, from the block grants. Through
this provision, the authors are acknowledging that these individuals--
children with disabilities--need protection. That is why they have
excluded them from the block grant.
However, in Ohio, only 24% of children with intellectual or
developmental disabilities, or IDD, who are on Medicaid rely on SSI.
The Graham-Cassidy proposal does not seem to protect the remaining 76%
of children on Medicaid with IDD, who are not on SSI and who are
therefore not exempted from block grants.
The proposal also does not seem to protect these children when they
grow up. A diagnosis of autism does not disappear when a child becomes
an adult. Under this language, children could lose critical services
and supports when they become adults.
Do proposals that cap or block grant Medicaid funds put all
individuals at risk, whether they are exempted from a block grant or
not? Do you believe that Medicaid beneficiaries like children, pregnant
women, and individuals with disabilities will be protected under this
proposal?
Answer. Proposals that cap or block grant Medicaid funds put all
individuals at risk, even if particular populations are exempted from
the block grant, because these policies eliminate the Federal
Government's guarantee to share with States the cost of all qualifying
Medicaid expenditures. Since Graham-Cassidy also ends the Medicaid
expansion, the consequences of this major change in financing falls
solely on those enrolled in the ``traditional'' Medicaid program:
newborns and other children, very low-income parents, pregnant women,
and low-income seniors and people with disabilities. It would affect
preventive and acute care services as well long term care (nursing home
care and home and community based services). Even though a few
populations--including children eligible based on disability--are
exempt from the per-capita cap, the aggregate cap on Federal spending
that is computed based on those caps will affect all populations and
the providers who serve them, too. This is because the per-capita caps
build up to an aggregate cap and States will have to manage that cap;
when States must cut program spending to keep within the cap, children
with special health-care needs will not be protected from those cuts.
The Congressional Budget Office's (CBO's) preliminary score of the
September 25th version of Graham-Cassidy-Heller estimated that the
legislation would reduce Federal Medicaid spending by about $1 trillion
over the 2017-2026 period.\10\ This includes elimination of the
Medicaid expansion funding but also the reductions in spending due to
the per-capita caps. As noted, these cuts grow over time as the trend
rates used to make the annual adjustments to the per-capita caps drop
beginning in 2025. Although Graham-Cassidy-Heller provides a modestly
less constraining trend rate than the Better Care Reconciliation Act
(BCRA), under both proposals the deepest cuts occur just beyond the
CBO's 10-year budget scoring window. The sheer volume of these cuts
(which also includes the impact of eliminating the Medicaid expansion)
makes it clear that it will be difficult to fully protect even
populations that may appear to be exempted from per-capita caps.
---------------------------------------------------------------------------
\10\ ``Preliminary Analysis of Legislation That Would Replace
Subsidies for Health Care With Block Grants,'' Congressional Budget
Office (September 2017), available at: https://www.cbo.gov/system/
files/115th-congress-2017-2018/costestimate/53126-health.pdf. CBO
projected that the rejected BCRA bill upon which Graham-Cassidy is
based would have cut Medicaid by $756 billion over 10 years. See
Congressional Budget Office letter to Hon. Mike Enzi re: H.R. 1628, the
Better Care Reconciliation Act of 2017: An Amendment in the Nature of a
Substitute [ERN17500], as posted on the website of the Senate Committee
on the Budget on July 20, 2017, available at: https://www.cbo.gov/
system/files/115th-congress-2017-2018/costestimate/52941-
hr1628bcra.pdf.
You are also correct in pointing out that the provision in Graham-
Cassidy to not allow children receiving SSI to be included in the
Medicaid block grant does not protect children with intellectual or
developmental disabilities who do not receive SSI from block grant
funding. Furthermore it leaves those children with SSI subject to the
constrained Federal funding that will result from the per-capita cap,
as described above.
nursing homes
Question. Three in five nursing home residents in Ohio rely on
Medicaid to cover the cost of their nursing home care.
What will the Medicaid cuts included in Graham-Cassidy mean to
seniors and their families and nursing home providers in States like
Ohio?
Answer. Medicaid is a lifeline for seniors (and people with
disabilities) who need nursing home care. Medicare does not pay for
long term nursing home services; there is very little commercial long
term care insurance; and most families do not have the resources to pay
nursing home costs out of pocket for an extended period of time.
Capping Medicaid funding is likely to jeopardize both access to and the
quality of nursing home services as States seek to manage their budgets
within Medicaid spending caps that get increasingly tight over time.
These caps could mean that nursing home providers see reductions in
provider payment rates, which could potentially lead some providers to
exit the market, making care less available. And caps puts quality at
risk for the nursing homes that remain open. Nursing home quality has
improved significantly in recent decades thanks to reforms instituted
by Congress, States and the nursing homes, but with significant
reductions in funding that progress may well unravel.
______
Questions Submitted by Hon. Robert P. Casey, Jr.
Question. Some supporters of the Graham-Cassidy amendment have
stated there are similarities between the program it establishes and
the successful CHIP program. Two questions:
Does Graham-Cassidy build upon and possibly expand CHIP?
Answer. No. Graham-Cassidy does not address CHIP and certainly does
not expand it. The Market-Based Health Care block grant language is
dropped into the CHIP statute but the Graham-Cassidy proposed
legislation in no way expands on CHIP. In fact, Graham-Cassidy could
have a detrimental impact on CHIP because it will strain State budgets
in ways that could force States to make hard choices about how to use
State dollars in support of CHIP and other coverage. It also weakens
Medicaid for all populations, including 37 million children; CHIP is
successful in large part because of the key role Medicaid plays for low
income children and children with significant medical needs.
Question. Are there similarities and/or differences between the
block grant
Graham-Cassidy proposes and the CHIP program?
Answer. Yes, like the block grant that Graham-Cassidy proposes,
CHIP is also a block grant that provides capped allocations to States.
It also must be regularly reauthorized as would the Graham-Cassidy
block grant and of course we have seen that even with the very popular
CHIP program, reauthorization is not certain or at least not always
timely.
But there the similarities end.
First, since CHIPRA, the funding for CHIP has intentionally been
set at levels above expected need to ensure that the funding gaps and
waiting lists that resulted from funding shortfalls in the early years
of CHIP no longer occurred. In addition, the CHIP funding formula
provides for several safeguards, including a contingency fund, to
further protect against shortfalls. By contrast, the Graham-Cassidy
block grant is funded at levels that are below the levels of funding
that would be available under current law and does not include the CHIP
financing protections.
Second, CHIP covers a relatively small number--8.9 million--of
mostly healthy children. Graham-Cassidy's block grant would end the
existing coverage for the more than 23 million people who are projected
to be covered by Medicaid and the Marketplace in 2019, many of whom are
in poor health; replacing this coverage is a much heavier lift than
CHIP.
Third, CHIP has been successful in part because the CHIP statute
requires that at least 90 percent of CHIP spending be used to cover
children and the basic standards of the coverage are spelled out in the
law. By contrast, the Graham-Cassidy block grant does not require the
funds be used for coverage nor does it provide minimum standards of
coverage.
Finally, CHIP operates within the context of the Medicaid program,
which covers many more children including children with significant
health-care needs. Medicaid, with its more flexible funding and strong
benefit guarantees for children, works as an important backstop for
children and for States. Graham-Cassidy eliminates the backstop (by
terminating the Medicaid expansion and tax subsidies in the
Marketplace) and weakens, through per-capita caps, the so called
``traditional'' Medicaid program.
Question. I understand that you think Graham-Cassidy should not be
adopted, but what new options and strategies do you think should be
provided to States to address growing Medicaid expenditures and improve
health-care outcomes?
Answer. Health-care spending in this country is higher than
spending in other developed countries on a per person basis and yet our
outcomes generally are far worse. The growth in health-care costs needs
to be constrained through system-wide changes that include some
fundamental changes in the way care is delivered and paid for. Medicaid
like other payers can do more to lower costs through better integration
of care (for example between physical and behavioral health), improved
data and technology, and by adopting reforms that reduce cost shifting
and instead focus on total cost of care. But it is important to note
that Medicaid expenditures have grown largely because it is covering
more people. On a per person basis, Medicaid has generally grown more
slowly than Medicare and commercial insurance in recent years.\11\ And
if there is one recurring complaint about Medicaid it is that it pays
its providers too little, not too much.
---------------------------------------------------------------------------
\11\ ``Medicaid Per Person Spending: Historical and Projected
Trends Compared to Growth Factors in Per Capita Cap Proposals,'' MACPAC
(June 2017), available at: https://www.
macpac.gov/wp-content/uploads/2017/07/Medicaid-per-Person-Spending-
Historical-and-Projected-Trends-Compared-to-Growth-Factors-in-Per-
Capita-Cap-Proposals.pdf.
Many State Medicaid programs and health plans and health systems
that serve Medicaid beneficiaries have been actively engaged in efforts
to reduce costs through delivery system and payment reforms, but they
face some considerable barriers, including homelessness and other
nonmedical issues that affect Medicaid health-care spending and health
outcomes, rising drug costs, an aging population, and difficulty
managing care for Medicaid beneficiaries who are also covered by
Medicare (almost 40 percent of Medicaid spending is on so called ``dual
eligibles'').\12\ These are some of the important issues that must be
tackled to improve care and lower costs, but these are not addressed
and, in key ways, are made worse by proposals to cut and cap Federal
Medicaid funding.
---------------------------------------------------------------------------
\12\ ``Medicaid Financing: The Basics,'' Kaiser Family Foundation
(December 22, 2016), available at: https://www.kff.org/report-section/
medicaid-financing-the-basics-issue-brief/.
Question. What are the implications of the per-capita cap included
in Graham-Cassidy for seniors and people with disabilities? Advocates
for the bill point to the trend rate provided for seniors and people
with disabilities, which is set at medical CPI plus one, as protecting
seniors and people with disabilities, but would this actually protect
---------------------------------------------------------------------------
seniors and people with disabilities?
Answer. No, the higher trend rate for seniors and people with
disabilities would not protect these populations. As noted, the trend
rate for these two groups of people is set at medical CPI plus one from
2020 through 2024 and then drops to medical CPI beginning in 2025. Even
though that trend rate is less constraining than the trend rate that
will be applied to other populations (and could accommodate expenditure
growth in some States), overall, capped funding will squeeze States'
Medicaid budgets and force tradeoffs. Under the proposal, the per-
capita caps build up to an aggregate cap and States will have to manage
to that cap. When they must cut program spending to keep within the
cap, seniors and people with disabilities will not be protected from
those cuts. In fact, seniors and people with disabilities are likely to
be particularly vulnerable to cuts because they account for the
majority of spending under the program. Some of the services that
seniors and people with disabilities receive are optional services
(e.g., home and community-based services) and could therefore be
particularly vulnerable to cuts as States seek to maintain mandatory
benefits across the program.
Caps fundamentally change the basic funding of the Medicaid
program, replacing the financial partnership between States and the
Federal Government with a system where all costs above the caps--
whether they can be anticipated or not, whether they are within a
State's control or not--are shifted to States. States that are not able
to shoulder significant new costs will need to reduce provider payment
rates and benefits, increase beneficiary costs, and/or reduce
eligibility. Since
Graham-Cassidy ends the Medicaid expansion, the consequences of this
major change in financing falls solely on those enrolled in the
``traditional'' Medicaid program: newborns and other children, very
low-income parents, pregnant women, and low-income seniors and people
with disabilities. The somewhat higher trend rates for low-income
seniors and people with disabilities will offer little protection as
States seek to manage their overall Medicaid budgets in a capped
funding environment.
______
Prepared Statement of Teresa Miller, Acting Secretary, Department of
Human Services, Commonwealth of Pennsylvania
Good morning Chairman Hatch, Ranking Member Wyden, and members of
the U.S. Senate Committee on Finance. Thank you for the opportunity to
be here today to speak about a proposal that would have a breathtaking
impact on residents of the Commonwealth of Pennsylvania.
I appreciate the invitation to share my perspective, as acting
secretary for the Pennsylvania Department of Human Services and former
Pennsylvania Insurance Commissioner, on how the Graham-Cassidy-Heller-
Johnson Proposal would impact Pennsylvania. However, I must express
disappointment that Congress is again considering rushing through a
major reform of our health-care system, rather than pursuing a
bipartisan, consensus-driven effort to enact targeted reforms to
stabilize our markets and ensure the Affordable Care Act (ACA) works
better for everyone going forward. I had the opportunity to testify a
few weeks ago before the Senate Health, Education, Labor and Pensions
(HELP) committee about just that topic. I was so optimistic after that
hearing because, for the first time in this debate, it appeared
Senators from both sides of the aisle were genuinely interested in
focusing on the problem (the need to stabilize the individual market)
and finding a solution to that problem, rather than using the problems
in the individual market as an excuse to reduce Federal funding and
consumer protections. And now I find myself here again talking about a
proposal that would make draconian cuts to Federal health-care funding
and force Governors across the country to make the most gut-wrenching
decisions they could possibly face.
Governor Wolf and I share the goal of ensuring that Pennsylvanians
have access to affordable, high quality health-care services so that
they can lead healthy and productive lives. And I believe that is a
goal we all share. I'm proud to say that the Commonwealth has been
diligently working toward that goal, and has made significant progress
thanks in large part to the ACA.
Before the ACA, sick people often couldn't get health insurance due
to a pre-
existing condition. If they were able to get coverage, they often paid
significantly more for it than someone without a pre-existing
condition. In some cases, these individuals would be offered a policy,
but it would not include coverage for their pre-
existing condition. Individuals with chronic medical issues or anyone
who underwent a costly procedure like a transplant could face annual
and lifetime limits that were often financially devastating. Women
would see higher coverage costs than men and perhaps not have
contraception or maternity care covered. Other critical services like
mental health and substance use disorder treatment services and
prescription drugs were often difficult if not impossible to find
coverage for. Most importantly, more than 10 percent of Pennsylvanians
and 16 percent of Americans nationwide went uninsured.
Since the ACA's passage, the national uninsured rate has fallen to
8.6 percent and Pennsylvania's uninsured rate has dropped to 5.6
percent--the lowest it's ever been. More than 1.1 million
Pennsylvanians have accessed coverage only available because of the
ACA, and that coverage is much more comprehensive than what was
previously available. There are 12.7 million Pennsylvanians, and more
than 40% of them--5.4 million--with pre-existing conditions cannot be
denied health insurance coverage due to the ACA. Approximately 4.5
million Pennsylvanians no longer have to worry about large bills due to
annual or lifetime limits on benefits, and 6.1 million Pennsylvanians
benefit from access to free preventive care services. More than 175,000
Pennsylvanians have also been able to access substance use disorder
treatment services through their exchange and Medicaid expansion
coverage. This is critical as our commonwealth and other States around
the country strive to combat the overwhelming impact of the opioid
crisis.
The narrative I continue to hear from Republicans in Washington is
that the ACA is imploding and that unless Congress takes action, it
will in fact implode. While the ACA has not been perfect, it is
critical that we level set and talk about the issues that exist and the
people those issues are really impacting. The ACA has had minimal
impact to the Medicare program and has enhanced the already very
successful Medicaid program by expanding access to millions more around
the country. Further, since the passage of the ACA, the employer
markets where small and large businesses purchase insurance products
for their employees have been stable and even seen costs grow at a
slower pace than before the ACA. The individual market, where we see
problems, is a very small market relative to these others, covering
only about 5 percent of Pennsylvanians. It is also a very important
market, because it is where individuals and families who do not have
access to coverage through their employer or public programs go to
purchase insurance. But, this is also the market that is heavily
subsidized through the ACA. About 80 percent of Pennsylvanians who
receive their coverage through the exchange receive tax credits to help
pay their premiums. In fact, the U.S. Department of Health and Human
Services estimated that 3 in 4 returning marketplace consumers could
find a plan for less than $100 per month in 2017. And, because of the
way the tax credits are structured based on income, these lower-income
consumers do not feel the full impact of premium increases. Further,
more than half of consumers who enroll in the exchanges are eligible
for cost-sharing reductions, additional financial assistance to low-
income consumers that helps them pay for their out-of-pocket costs like
deductibles and co-pays. However, the people who this market may not be
serving well are those that are not eligible for financial assistance,
which is about 1-2 percent of Pennsylvanians. In a perfect world, I
would like to see the income level for subsidies increased to help this
1-2 percent, but if that is not possible I think there are still ways
to improve affordability and their experience moving forward.
I also want to be clear that we are seeing the individual market
stabilize in Pennsylvania. Assuming that the current Federal regulatory
structure continues, our insurers requested an average increase of 8.8
percent statewide for 2018 plans. When they filed their rate requests,
we asked insurers to provide information on what they would need to
request if cost-sharing reductions payments were not made or if the
individual mandate was not enforced. The differences are stark. If
cost-sharing reductions are not paid, they reported they would need to
request a statewide average increase of 20.3 percent. If the individual
mandate is not enforced, they say they would seek a 23.3 percent
increase. If both changes occur, our insurers estimate that they would
seek an increase of 36.3 percent. While Pennsylvania has not released
final rates, it is critical to recognize that if the increases are
higher than that 8.8 percent it is not because the ACA is failing--it
is because of the uncertainty and inaction here in Washington, DC.
Instead of furthering that uncertainty, I believe we need to build
upon the foundation of the health-care system we have and make
targeted, common sense changes that will improve the ACA and make it
work better for the people it is not working perfectly for today.
Starting over, or even moving backwards as I believe the
Graham-Cassidy-Heller-Johnson proposal will do, will not better serve
Pennsylvanians or Americans throughout the Nation. With that context, I
would like to offer my department's thoughts on the Graham-Cassidy-
Heller-Johnson proposal and contrast that proposal with ideas on what a
real bipartisan solution that would improve our health-care system
could look like.
the graham-cassidy-heller-johnson proposal's
potential impact on pennsylvania
As someone with experience as an insurance regulator in two
different States and as a Federal regulator, I truly believe States are
in a better position to make decisions impacting our residents. We know
our markets better and we are more nimble and able to respond to issues
impacting our consumers. So, when we hear that you want to give us more
flexibility as States, we are interested in hearing more.
However, as it stands, I don't believe that this flexibility
exists. The proposal's sponsors say that they want to turn power over
to States to create their own health-care system, and claim to do so by
creating a block grant that levels the playing field between expansion
and non-expansion States. As I will detail, this creates an
insurmountable burden on States that want to maintain their current
coverage levels, let alone expand them. For some States, this may be an
opportunity to craft a health-care system as they see fit, but given
how Federal funding is projected to decrease over time compared to
funding levels if the proposal weren't enacted and the fiscal cliff if
the block grant funding ends after 2026, this flexibility is illusory.
At some point, all States will be left to fill sizable gaps in their
State budgets, and we will likely see legislative crises to make up the
funding loss. States may then be forced to either impose significant
tax increases, further coverage losses, or both. Is that really the
flexibility we need?
Both our internal analysis and independent external analyses
conclude that the Graham-Cassidy-Heller-Johnson proposal would result
in the loss of billions of dollars in Federal funding. In our internal
estimate, assuming average cost growth, Pennsylvania would lose $30
billion in Federal funding over the next decade. Other independent
external analyses estimate losses ranging from $15 billion to $22.5
billion over that period. Whether the ultimate amount is at the low or
high end of that range, we're looking at losses that the State has no
way to make up. Pennsylvania is facing a $2 billion structural deficit
in our budget. We don't even have a balanced budget for this current
fiscal year, 3 months into it. And we certainly don't have the ability
to cover the loss of billions of dollars in Federal funding. This
extreme shift in funding will result in a fiscal crisis beyond what
Pennsylvania has experienced to date.
These losses are due to a major restructuring of the Federal health
care financing structure. As the National Association of Medicaid
Directors put it, this would be the largest intergovernmental transfer
of financial responsibility from the Federal Government to States in
our country's history. This proposal would dismantle the Medicaid
expansion of the ACA, which has resulted in the coverage of more than
715,000 newly eligible Pennsylvanians, and the individual market
subsidies, which reduce health insurance costs for hundreds of
thousands of Pennsylvanians who purchase commercial coverage on their
own, typically because they are self-
employed or do not get health insurance through their employer.
Medicaid expansion and individual market subsidy funding would be
replaced with a block grant using a formula that appears to
disadvantage States like Pennsylvania that have acted responsibly to
expand Medicaid and increase health-care coverage. Based upon an
analysis from the Kaiser Family Foundation, we estimate Pennsylvania
would receive 20 percent less in Federal dollars under the proposed
block grant for the Medicaid expansion population, compared to the
amount projected under the ACA for the Medicaid expansion population
over the next decade.
Not only does the Graham-Cassidy-Heller-Johnson proposal
drastically and dangerously restructure Federal financing for the
Medicaid expansion and individual market populations, it also
fundamentally changes the Federal financing structure for what are
known as ``traditional'' Medicaid-eligible populations: low-income
adults and elderly, children, pregnant women, and individuals with
disabilities. Currently, the Federal and State government share the
cost of providing coverage for these populations, with the Federal
Government covering a set percentage of their cost of care. These are
our most vulnerable populations, yet this proposal would set a per-
capita cap on Federal funding for these individuals, and that Federal
funding would increase at a rate below actual cost growth, resulting in
plummeting Federal funding over the years as actual costs outpace the
Federal cap. Children are especially hard hit by this proposal--Avalere
Health projects that, nationally, Federal Medicaid funding for kids
would be slashed by more than 10 percent in the next decade and more
than 30 percent by 2036. I struggle to see how a proposal that cuts
coverage for kids, who are our future, could ever be in the best
interest of Pennsylvanians.
I want to make sure you understand just how critical Medicaid is to
Pennsylvanians. Medicaid serves 2.8 million Pennsylvanians, or 22
percent of the commonwealth's population. This includes 1.2 million
children, nearly 250,000 seniors, 565,000 individuals who receive
outpatient mental health services, and 215,000 individuals relying on
substance use disorder treatment. In 2015, Medicaid paid for over
58,000 births in the commonwealth--nearly 40 percent of Pennsylvania's
total births.
These statistics show how important Medicaid is to our population,
but let me share with you a personal story of Medicaid's impact. Debra
S., age 60, and her husband, Wayne S., age 61, have four grown children
and six more they have adopted or care for through foster arrangements.
All but two of the adopted children have significant developmental
disabilities. Four of the six adopted children's birth mothers suffered
from a substance use disorder, reflecting the growing national opioid
epidemic. Medicaid makes it possible for most of Debra and Wayne's
children to live at home rather than in an institution--covering
everything from prescription drugs to home nursing visits to the
nutritional drink for their adopted son's tube feedings.
These Federal funding cuts would force Governors across the country
to make impossible decisions. We would be tasked with replacing these
Federal funds or be forced to cut services, reduce provider payments,
or eliminate coverage for some of our most vulnerable citizens. Who
should receive health care--Debra and Wayne's children? A young adult
struggling with an opioid addiction who needs our help to receive
recovery services? A mom fighting breast cancer? A senior who has
worked hard all his life and needs access to quality health care to age
with dignity? These are decisions that no Governor should have to make,
and Pennsylvania is not interested in the ``State flexibility'' to make
decisions about who deserves health care and who must go without.
This proposal also chips away at a number of the ACA's protections
for people in the individual market, by resurrecting several proposals
in legislation floated over the summer, including a repeal of the
individual mandate, which would do nothing but exacerbate the stability
issues we currently face. The bill also does not include funding for
cost-sharing reduction payments. The ACA's ``three-legged stool'' in
the individual market--the individual mandate, non-discrimination
requirements for people with pre-existing conditions, and subsidies and
cost-sharing reductions--was designed to help insurers balance the
added risk of individuals with pre-existing conditions while avoiding
the risk of adverse selection where people only enter the market when
they are sick and need care. The proposal's proponents may point to
proposed funding to stabilize the individual market as a sweetener to
keep insurers from raising rates or exiting the market due to the
mandate repeal, but I fear that will not be enough to prevent rate
increases and additional insurer market exits.
As I mentioned previously, due to the implementation of the ACA and
Medicaid expansion Pennsylvania's uninsured rate is at a historic low
of 5.6 percent. If the Graham-Cassidy-Heller-Johnson proposal is
adopted, we are confident this positive trend will be reversed and the
commonwealth's uninsured rate will skyrocket. While the Congressional
Budget Office (CBO) will not have an opportunity to provide a full
picture of how this plan will impact insurance rates, many of the
provisions in the Graham-Cassidy-Heller-Johnson proposal were
previously considered in the bills that failed in the House and Senate.
Those bills would have, according to CBO estimates, resulted in
anywhere between 23 million and 32 million Americans losing health-care
coverage by 2026 and take us back to the days when too many residents
had to seek treatment in emergency rooms.
I've been thinking a lot over the past few days about what we would
do in Pennsylvania if this bill passes and becomes law. And honestly, I
struggle to figure out how we would respond. We would have 2 years to
completely revamp our health-care system, work with stakeholders to
figure out what this new system could look like, develop whatever
infrastructure would be needed, make system changes required, pass
legislation, get any necessary Federal waivers, and a host of other
activities. All of this would need to happen apparently without Federal
funding to support these essential planning activities. The ACA gave
States almost 4 years and a lot of funding to support their work.
And after 7 years, the proposed block grant funding disappears and
it is unclear from the proposal what if any funding would continue to
be available or if the State would be left holding the bag to fund
whatever system we put in place. That alone would make it very
difficult to put a plan in place in Pennsylvania by 2020. In my
experience, State legislatures don't want to develop a major system
that relies upon Federal dollars without a guarantee of sustainable
Federal funding support. But let me be clear--providing implementation
funding or extending this funding scheme indefinitely into the future
would not fix the insurmountable flaw in this bill: the staggering cut
in Federal funding.
opportunities for bipartisan solutions to stabilize the
individual health insurance market
As I've mentioned, the real problem we face is the need to
stabilize the individual health insurance market. I urge you to resume
the work of Senators Alexander and Murray to enact targeted, bipartisan
reforms to stabilize the individual market, using as a model the
reforms that Governor Wolf and a group of bipartisan governors have
proposed. Their proposal would stabilize the market in the short-term
and, through bipartisan compromises, would ensure the long-term health
of individual markets around the country. These proposals include
guaranteeing Federal payment of cost-sharing reductions to compensate
insurers for reducing out-of-
pocket costs for low- and middle-income Americans; adequately funding a
reinsurance program to help insurers cover the costs of the sickest
enrollees, which would reduce premiums for everyone; and addressing the
underlying costs of health care through opportunities like increased
cost and quality transparency and a continued drive away from a fee-
for-service payment system that incentives the increased utilization of
health-care services and towards a value-based payment system that
rewards prevention and high-quality care.
making changes on a realistic and careful timeline
If any changes are going to come to the ACA, they must be done in a
way that does not disrupt care, coverage, and protections for consumers
in the interim. Given the conversations taking place in the Senate, I
am extremely concerned that this is not the path you are taking.
We have had less than 2 weeks to analyze this proposal, a bill that
would have a dramatic effect on the approximately 3.2 million
Pennsylvanians with coverage through Medicaid and the Federal exchange.
I understand that the Senate is supposed to vote on this bill this
week, before receiving a complete CBO analysis of the bill's impacts on
coverage rates and premiums.
By rushing through a plan that we do not fully understand and have
not fully evaluated, and throwing States into a brief, unfunded,
chaotic implementation period to restructure our health-care system, I
fear that you will be jeopardizing the health and financial well-being
of the individuals we serve. Washington must keep the needs of
consumers at the forefront of their minds as conversations continue,
and I truly hope that Congress and the Trump administration will slow
down and take a more deliberative approach than they have thus far.
Significant and swift changes to our health-care system could have a
devastating impact on the people that rely on it every day. This is
about Americans accessing and affording care that is vital to their
health and well-being. We cannot return to a time when people are
forced to accept less coverage at an increased cost, and make tough
choices between their finances or their health.
Please do not paper over spending cuts and diminishment of consumer
protections using the guise of State flexibility. On behalf of
Pennsylvanians, on behalf of our children, seniors, and individual with
disabilities--our most vulnerable populations--I implore you to return
to the bipartisan process that the Senate was engaging in earlier this
month, and craft a compromise bill to stabilize the individual market
and improve our current system.
Again, thank you for allowing me to speak with you today. I would
be happy to take any questions that you might have.
______
Questions Submitted for the Record to Teresa Miller
Questions Submitted by Hon. Claire McCaskill
Question. Under current law, could States elect to pursue auto-
enrollment through a section 1332 waiver?
Answer. I do not believe there is anything that would prohibit a
state from pursuing auto-enrollment through a 1332 waiver today.
Question. Does the Graham-Cassidy-Heller-Johnson proposal require
States to establish an auto-enrollment mechanism?
Answer. No.
Question. Does the Graham-Cassidy-Heller-Johnson proposal eliminate
the individual mandate?
Answer. Yes. The proposal eliminates the individual mandate
effective retroactively (January 2016).
Question. Do you anticipate that the number of individuals with
insurance coverage will decrease under the Graham-Cassidy-Heller-
Johnson proposal and that uncompensated care costs may rise?
Answer. Yes. The proposal would certainly result in fewer
individuals with insurance coverage, which would increase the amount of
uncompensated care. Although we do not have the benefit of a full
Congressional Budget Office (CBO) score, the CBO did project this
proposal would result in ``millions'' of people with comprehensive
health insurance losing their coverage.
A literature review by the Kaiser Family Foundation found that
Medicaid expansion has positive effects on multiple economic outcomes.
National, multi-state, and single state studies show that States
expanding Medicaid under the Affordable Care Act (ACA) have realized
budget savings, revenue gains, overall economic growth, and reductions
in uncompensated care costs for hospitals and clinics. Last year alone,
thanks to the ACA, hospitals in Pennsylvania experienced a $129 million
decline in uncompensated care.
______
Questions Submitted by Hon. Robert Menendez
Question. The United States is facing a rapidly aging population.
Medicaid pays for the long-term care needs of millions of seniors, a
number that is expected to grow rapidly in the near future. How will
funding caps for Medicaid funding impact the ability of States to meet
the needs of the elderly? In particular, can the needs of the growing
number of individuals afflicted by Alzheimer's disease be met under the
Graham-Cassidy-Heller-Johnson proposal?
Answer. According to the Pennsylvania Department of Aging's 2016-
2020 State Plan on Aging, out of Pennsylvania's more than 12.8 million
residents, approximately 2.9 million are adults age 60 and older, and
more than 300,000 are aged 85 and older. By 2020, the population of
older Pennsylvanians is projected to increase by 25%.
In Pennsylvania, we are in the process of implementing a program
called Community HealthChoices, which aims to allow older
Pennsylvanians and individuals with a physical disability to receive
services in their community and in their homes, rather than a nursing
home. We all know it is much more cost effective to allow people to
receive services in the community and, this is where most of us want to
age if possible. Under current Medicaid rules, nursing homes are the
default in terms of what Medicaid covers, even though it is the most
expensive setting for long term care services. If we must absorb
Medicaid cuts of anywhere from $15-30 billion over the next decade, I
worry about our ability to continue to move to community based services
for older Pennsylvanians. Yet, if we do not move in this direction,
both the State and Federal Government will be on the hook for the most
expensive type of long term care services. Cuts of the magnitude
required by this legislation to Medicaid will certainly have an impact
on our ability to meet the needs of older Pennsylvanians. Our Governor
will be forced to make unconscionable decisions about which services we
will no longer be able to provide or who will no longer be able to
receive services if this legislation were to pass.
Question. Families who have children with special needs often face
an uphill battle in accessing services. What protections does the
Graham-Cassidy-Heller-Johnson bill offer them to ensure their children
are not cut off from care for their conditions? That a young child
isn't forced to go without care because they have hit an annual cap? A
lifetime cap?
Answer. Under this proposal, whether children with special needs or
pre-existing conditions are protected will depend largely on where they
live. The bill allows States, through their block grant program, to
waive certain important requirements that protect people with pre-
existing conditions today. States could allow insurers to charge people
with pre-existing conditions more based on their health status. While
individuals cannot technically be denied coverage, they could be forced
to pay more for that coverage, which may leave some priced out of
coverage they need. Additionally, States can waive essential health
benefit requirements, so people with pre-existing conditions may not
have the benefits they need available to them if they live in a State
that decides to waive some of those benefits. While the ACA's
prohibition on annual and lifetime dollar limits remains, the
prohibition only applies to limits on essential health benefits, which
can be waived by States.
Having said that, I think the larger issue that will impact
children with special needs, like it will impact everyone else, is the
significant loss of Federal funding that will force Governors across
the country to figure out how they are going to revamp their health-
care systems with less money. In States like Pennsylvania that would
not otherwise choose to waive essential health benefits, we are not
going to be able to make up for this loss of Federal funding and will
be forced to make impossible decisions about who will no longer have
access to health care and/or what services will no longer be covered.
______
Questions Submitted by Hon. Bill Nelson
Question. The Graham-Cassidy bill repeals the Affordable Care Act's
Medicaid expansion, premium tax credits, and cost-sharing reduction
payments and instead creates a block grant.
It is my understanding that the block grant funding ends after 2026
under the Graham-Cassidy bill. What happens to the individual
marketplace after 2026?
Answer. I am concerned if this proposal passes, the individual
market in Pennsylvania would collapse long before 2026. By
retroactively repealing the individual mandate and creating significant
uncertainty about the future, I think it is likely insurers would exit
the market in the next few years. If for some reason our individual
market had not collapsed before then, it is hard to imagine how it
could withstand the changes in 2027. At that point, not only would we
not have the individual mandate, but the block grant funding allowing
States to implement cost-sharing reductions, premium tax credits or
other methods of providing financial assistance to help people pay for
coverage, would be gone but, the guaranteed issue requirement for
companies would still be in place.
The ACA was predicated on three interrelated principles--the
individual mandate, the requirement insurers cover anyone who signs up
for coverage, and the availability of financial assistance to help
people pay for coverage. If you remove any of these three provisions,
or two of them as this proposal would do, it sets the market up to
fail. In this scenario, only the sickest individuals are going to sign
up for coverage, which ultimately leads to a death spiral. I do not
know how our individual market would survive such a scenario.
Question. Would you say that gutting the current individual
marketplace by changing it to a block grant from 2020 to 2026, and
creating a funding cliff after 2026 is good for the stability of the
individual insurance market? Insurers are already having trouble
setting their 2018 rates because the administration won't commit to
funding the CSRs. How do you expect them to plan for 2027?
Answer. This proposal is not going to be good for the stability of
the individual market, either in the short term or the long term. This
bill retroactively repeals the individual mandate and does not replace
it with any continuous coverage requirements or anything that might
assist with adverse selection concerns. Consequently, I am very
concerned about the impact this bill would have on the individual
market in the next few years, before the State block grant kicks in. In
Pennsylvania, our individual market is stabilizing. Our proposed
increases of 8.8 percent in this market are evidence of this
stabilization.
However, when we asked insurers to file their rates, we asked them
to estimate their increases if the individual mandate were to go away
and/or if the CSR payments were not made. If both of those things
happened, as proposed in this bill, in Pennsylvania, we will be looking
at a statewide average increase in the individual market of 36 percent.
So, if this bill passes, we will certainly see significant increases as
a result. But, my bigger fear is that we will see insurers exit the
market because of the instability created by the combination of no
mandate and no CSR payments and a very uncertain future. And, those are
the problems we have in the immediate future. I do not know that we
would have any insurance companies still participating in the market in
2026. If we did, it is hard to imagine how they would plan for 2027
when the State block grant funds end.
Question. I'm the former Florida insurance commissioner, and I've
seen what can help stabilize an insurance marketplace. That's why I,
with my friend from across the aisle, Senator Collins, have introduced
the Lower Premiums Through Reinsurance Act to help States establish
their own reinsurance programs. Do you think this bill is a good
solution to help stabilize the ACA's individual market?
Answer. The Graham-Cassidy proposal, even though it does include a
short-term reinsurance program, would destabilize the individual
market. While a reinsurance program could be a key component of a bi-
partisan solution to help stabilize the individual market, such a
program, on its own, is not enough. That is the problem with the
reinsurance program in the Graham-Cassidy proposal. It won't be nearly
enough to make up for the fact that the proposal retroactively repeals
the individual mandate and eliminates CSR payments.
As we discussed during the hearing, if we are serious about
stabilizing the individual market, we should let Senator Alexander and
Senator Murray continue the work the HELP Committee began in early
September.
Question. Medicaid is the largest health-care program for children,
covering more than 30 million kids. As it is currently structured, the
Medicaid program gives States flexibility to innovate and pursue
delivery system reforms. How will States be able to transform care and
pursue delivery system reforms to improve child health outcomes if the
Medicaid program is gutted under either a cap or block grant?
Answer. If we are forced to make the draconian cuts required by
this bill, all of our efforts would be focused on how we cut $15-30
billion from our Medicaid program. Instead of using our time and
resources to continue down the path of pursuing delivery system reforms
and focusing on improving outcomes, we will be left making very
difficult decisions about what services we will no longer provide or
who will no longer be able to receive services.
______
Questions Submitted by Hon. Sherrod Brown
intellectual and developmental disabilities population
Question. The Graham-Cassidy proposal includes a provision that
seems to try and protect children with intellectual or developmental
disabilities who are on Medicaid by exempting those receiving
Supplemental Security Income, or SSI, from the block grants. Through
this provision, the authors are acknowledging that these individuals--
children with disabilities--need protection. That is why they have
excluded them from the block grant.
However, in Ohio, only 24% of children with intellectual or
developmental disabilities, or IDD, who are on Medicaid rely on SSI.
The Graham-Cassidy proposal does not seem to protect the remaining 76%
of children on Medicaid with IDD, who are not on SSI and who are
therefore not exempted from block grants.
The proposal also does not seem to protect these children when they
grow up. A diagnosis of autism does not disappear when a child becomes
an adult. Under this language, children could lose critical services
and supports when they become adults.
What is the likely impact of Graham-Cassidy on services for the
vulnerable populations of seniors and people with disabilities who wish
to receive services in their home and communities?
Answer. In Pennsylvania, we are in the process of implementing a
program called Community HealthChoices, which aims to allow older
Pennsylvanians and individuals with a physical disability to receive
services in their homes and communities, rather than a nursing home. We
are also planning to expand our home and community based services for
individuals with intellectual disabilities and autism through a new
Community Living Waiver program. We all know it is much more cost
effective to allow people to receive services in the community and this
is where most of us want to receive services if at all possible. Under
current Medicaid rules, nursing homes are the default in terms of what
Medicaid covers, even though it's the most expensive setting for long
term care services. But, if we have to absorb Medicaid cuts of anywhere
from $15-30 billion over the next decade, I worry about our ability to
continue to move to community based services for individuals with
disabilities and older Pennsylvanians who are truly the most
vulnerable. And, yet if we don't move in this direction, both the State
and Federal Government will be on the hook for the most expensive type
of long term care services.
nursing homes
Question. Three in five nursing home residents in Ohio rely on
Medicaid to cover the cost of their nursing home care.
What will the Medicaid cuts included in Graham-Cassidy mean to
seniors and their families and nursing home providers in States like
Ohio?
Answer. When States are faced with cuts of this magnitude, for
Pennsylvania our losses are expected to be somewhere between $15-30
billion over the next decade, there are only three levers available. We
will have to decide what services we may no longer be able to provide,
who may no longer be able to receive services and/or where we can make
reductions in provider payment rates. More than 55,000 individuals per
month rely on Medicaid to pay for their services in a nursing home. I
am afraid seniors and their families will see a reduction in services
as we are left making impossible decisions and forced to make deep cuts
to the program. It's entirely possible nursing home providers would see
their Medicaid payment rates impacted as States make significant cuts
to their Medicaid programs.
jobs
Question. The Graham-Cassidy proposal could cost people their jobs
when area hospitals are forced to cut services to patients and lay off
workers.
Earlier this year, I met with hospitals across the State of Ohio
who shared their concerns over proposals like Graham-Cassidy, and what
they would mean for communities across Ohio.
In Toledo, a representative from ProMedica hospital said that
proposals that include massive cuts to Medicaid ``could potentially
result in massive job losses and even hospital closures across our
industry.''
In Cleveland, the CEO of MetroHealth Hospital, said: ``a
replacement plan must not create gaps in coverage. This is about
people, millions of them, who will suffer needlessly if they go without
health care. Losing health care affects more than their health. It
affects their ability to work, support for their children's education,
and the overall economy of the community. Significant increases in the
number of uninsured and under-insured patients will strain the finances
of health systems and will negatively impact both medical services and
employment.''
Do you agree with the concerns above? What would this proposal mean
for health-care jobs in States like Pennsylvania and Ohio?
Answer. I share these concerns about what this proposal would mean
for jobs in Pennsylvania and around the country. For Pennsylvania, the
Medicaid expansion generated an infusion of over $1.8 billion in direct
care health spending into the commonwealth in calendar year 2015 and
the addition of 15,500 jobs in Pennsylvania in year one. Although I
can't speak to the effect of the Graham-Cassidy bill specifically on
Pennsylvania, given how little time we've had to review it, I can point
to a study by the Commonwealth Fund and George Washington University's
Milken Institute on the effects of the AHCA, the House bill proposed
this summer, which also would've cut Medicaid expansion. The study of
that bill concluded that, nationally, nearly 1 million jobs would be
lost due to the AHCA due to a sicker workforce, a loss of health-care
jobs, and economic downturn. They estimated that Pennsylvania would
lose 85,000 jobs by 2026--second only to New York.
______
Questions Submitted by Hon. Robert P. Casey, Jr.
Question. Ms. Miller, the sponsors of the Graham-Cassidy proposal
have said that States with budget challenges would see relief under the
Graham-Cassidy proposal. Is this accurate? Would Pennsylvania's budget
be helped by the funding proposal in Graham-Cassidy? What would the
impact of this proposal be on the State's ability to pay for the
necessary health care for its residents?
Answer. Let me start by talking about who Medicaid serves in
Pennsylvania. We serve 1.2 million children, nearly 250,000 seniors,
565,000 individuals who receive outpatient mental health services, and
215,000 individuals relying on substance use disorder treatment.
Medicaid pays for nearly 40% of Pennsylvania's total births.
Both our internal analysis and independent external analyses
conclude that this proposal would result in the loss of billions of
dollars in Federal funding for Pennsylvania, anywhere from $15 billion
to $30 billion over the next decade. Whether the ultimate amount is at
the low or high end of that range, we're looking at losses that the
State has no way to make up. Pennsylvania is facing a $2 billion
structural deficit in our budget now. We don't even have a balanced
budget for this current fiscal year, three months into it. We certainly
don't have the ability to cover the loss of billions of dollars in
Federal funding. This extreme shift in funding will result in a fiscal
crisis beyond what Pennsylvania has experienced to date.
These funding cuts would force Governor Wolf to make truly
impossible decisions. We would be left with the only three levers that
exist when we are forced to cut Medicaid. We would have to cut
services, reduce provider payments, or eliminate coverage for some of
our most vulnerable citizens. I worry about not only the 1.1 million
Pennsylvanians in the expansion population and on the marketplace, but
also the 2.1 million Pennsylvanians served through traditional
Medicaid. This level of funding cut would have far-reaching impacts on
people served by Medicaid in Pennsylvania, which is almost a quarter of
our population.
______
Prepared Statement of Hon. Rick Santorum,
a Former U.S. Senator From Pennsylvania
In July of 1996, after two vetoes by President Clinton, the Senate
passed The Welfare Reform Act of 1996. That reform ended a New Deal Era
Federal entitlement know as Aid to Families with Dependent Children and
replaced it with a block grant to the States called Transitional
Assistance to Needy Families. I was the floor manager of that bill and
worked closely with Representative Clay Shaw in the House and numerous
governors to craft this reform.
President Clinton, from his experience as Governor of Arkansas,
realized the faults in this federally controlled open-ended entitlement
that was both inefficient and ineffective in addressing poverty. To his
great credit, he accepted that this broken program was in need of a
major overhaul. He boldly campaigned on ``ending welfare as we know
it.''
What passed the Congress was more than a major overhaul. It
repealed the old system and replaced it with a federalist solution that
gave power and a block grant to the each State. The objective then, as
with the bill before this committee, was to entrust sufficient
resources and decisions into hands closer to the people in need so they
can devise innovative solutions better suited for the unique needs of
the people in their community. This was to be funded by a clearly
defined amount of money that would be limited over time so State and
local authorities could set their priorities.
Many progressive voices in and outside of the administration
claimed that cruel assault on the poor would lead to rampant poverty,
the deaths of thousands if not millions over time. Cries that States
couldn't be trusted with caring for their poor, lack of resources, even
though there was no reduction in spending in the near term, mean
spirited requirements like insisting that the able-bodied work as a
condition to receiving cash assistance, were all used to paint
supporters of this approach as cruel and uncaring.
Fifty-one Republicans voted for passage along with 23 Democrats,
including then Senators Joe Biden and John Kerry, as well as, I should
note, the ranking member of this committee, Ron Wyden. Most of the
States took on the challenge and transformed welfare. Within a few
years welfare rolls were cut in half nationwide and by more than 90% in
some States. The much feared reduction in the rolls did not however
result in the much predicted increase in poverty. In fact, poverty
among the most chronically poor went down, in some cases to record
lows, and employment, particularly among the hardest to employ went up.
This novel idea worked for those on welfare and for the taxpayer who
has not seen an increase in the block grant in 20 years!
It was this experience in bipartisanship and the frustration of
seeing the process bog down in Washington that lead me to reach out to
a small group of Governors, Senators, and House members to discuss
designing a similar approach to addressing both Medicaid and ACA.
Contrary to reports that this is a hastily patched together last minute
Hail Mary, Senator Graham, Congressman Meadow and their staffs have
been working with a group of Governors lead by Scott Walker and Doug
Ducey for several months.
Before I go into the details of the repeal and replacement of the
ACA, let me briefly address a proposal that has been debated in the
Congress for several months that I had nothing to do with. This is a
proposal that puts Medicaid on a sustainable funding path while giving
States both the resources and predictability necessary to craft a
program to care for those in most need. The most significant criticism
we hear about GCHJ is the Medicaid per-capita cap will strangle this
program to the disadvantage of the poor. I understand the per-capita
cap is something that President Bill Clinton proposed and in 1995, 46
Democratic Senators including the current ranking member of the HELP
committee signed a letter in support of it. The claim is the per capita
annual growth rate which starts as CPI Medical plus one and which
settles at CPI Medical for the blind, elderly and disabled and CPI U
for the younger and healthier population is insufficient.
I find this criticism particularly perplexing coming from those who
supported Medicaid expansion and are now proposing Medicare for all.
One of the principle selling points advanced by their advocates is that
these government programs are the most efficient provider of health
services. If that is true then pegging that program to an inflation
rate that includes these so-called inefficient and profitable private
sector plans should be a bonanza for Medicaid. How can you argue on one
hand that everyone should be in a government program because it will
increase quality and lower cost and then turn around and say that this
government program will fail unless it gets more money than the private
sector plans?
In spite of the intellectual inconsistencies of the advocates of
Medicaid, GCHJ attempts to mollify these concerns by permitting States
to use up to 20% of the GCHJ block grant to support the State's
Medicaid program. In most States that will eliminate or at a minimum
greatly reduce any funding shortfall.
That provision of GCHJ was one of the reasons that I suggested a
``second'' block grant to Senator Graham earlier this spring. The key
to designing an effective solution to a rapidly changing and innovative
sector of our economy like health care is a combination of equally
distributed, sufficient but limited resources, the flexibility to adapt
to its dynamic nature and multiple competitors to allow for innovation.
The ACA provides none of those keys, GCHJ does.
Let me address each one of those keys. Unlike the ACA which
distributes funds based upon how States align with ACA requirements,
GCHJ is designed to create funding parity among the States and let the
States decide how to best spend that money. The allocation is made by
distributing the resources on a per capita allocation based upon the
number of people between 50%-138% of poverty. That amount is multiplied
by the number of people at that level of poverty in each State. In
order to minimize the impact of the transition to parity for the
expansion States, GCHJ establishes a base year in 2020 based upon
current levels of total funds received by the States under the ACA. The
formula is phased in over 10 years to achieve parity among the States.
There are three other provisions to further limit the impact on
expansion States, non-expansion States are limited to 25% growth per
year for the first 6 years of the formula. The 10% State funding match
required by the ACA in 2020 is eliminated. Finally, States whose year
over year increases fall below the rate of medical inflation (CPI-M)
can buy back the reductions in Disproportionate Share payments
eliminated under the ACA. As a result, only a handful of high cost
Medicaid States see a reduction in projected spending.
In addition to putting Medicaid under some spending restraint, GCHJ
takes another open ended unsustainable entitlement, the ACA, and puts
it on a budget. As was the case in 1996 with welfare, this bill
restrains spending on an inefficient and failing program. Contrary to
the explosive rhetoric the bill does not slash spending. In fact, there
are voices on the right and left who oppose this proposal because of
the amount of taxes and spending. That usually means you are somewhere
at or near appropriate levels of spending. This bill allocates $1.2
billion, all the ACA revenues projected to be collected over the budget
window minus a few unpopular taxes like the medical device tax and the
individual and employer mandate. Those States that wish to continue an
ACA insurance and funding regime could simply adopt the identical
mandates in their State implementing legislation.
Unlike the Federal Government, States, like families and
businesses, are used to living within a budget. They can't just borrow
seemingly unlimited amounts of money. Medicaid, and particularly
Medicaid Expansion, encourage spending and create no incentive to be
efficient or effective. The program that welfare reform repealed had a
similar track record. They took responsibility to craft a superior
system to care for those falling through the cracks in our country,
welfare reform demonstrated they will and can.
This leads me to the last reason to support this bill. Allowing the
States the flexibility to innovate, compete and imitate were the keys
to welfare reform's success. Just look at what Rhode Island, Arkansas
and Indiana have done with waivers in Medicaid and Medicaid Expansion.
Some have suggested that States prior to the ACA didn't create
insurance markets that were affordable and accessible to the individual
market. That is true, but they didn't have $1.2 trillion either.
The ACA is failing, and it is clear that the Democrats have no
interest in structural changes to make it work and Republicans have no
interest in propping up a doomed plan. This allows those areas of the
country that want to continue with the ACA to do so and those that
believe there is a better way to give it a try all within a sustainable
budget.
______
Question Submitted for the Record to Hon. Rick Santorum
Question Submitted by Hon. Sherrod Brown
drafting process and advocacy organizations
Question. Creating thoughtful, responsible, and effective
legislation requires the input of diverse subject matter experts,
representing different stakeholder communities. The Graham-Cassidy
proposal is a remake of the entire U.S. health-care system, which
necessitates input from groups like advocacy organizations,
professional societies, or other reputable associations.
Have any organizations from the categories listed above endorsed
the Graham-Cassidy bill that you helped create?
Answer. The Catholic Medical Association supported the Graham-
Cassidy development effort.
______
Prepared Statement of Dennis G. Smith, Senior Advisor for Medicaid and
Health Care Reform, Arkansas Department of Human Services
I am Dennis G. Smith, Senior Advisor for Medicaid and Health Care
Reform for the Arkansas Department of Human Services (DHS). It is a
privilege to be with you today to convey Governor Asa Hutchinson's
support for the Graham-Cassidy-Heller-Johnson proposed amendment to
H.R. 1628, the Better Care Reconciliation Act of 2017 (BCRA) under
consideration by the U.S. Senate. My remarks will focus on Federal
funding for private insurance subsidies, the use of the Children's
Health Insurance Program (CHIP) as the model for re-establishing the
relationship between States and the Federal Government, Medicaid per-
capita caps, and work requirements.
federal funding for subsidies
The Graham-Cassidy-Heller-Johnson proposed amendment would provide
States with nearly $1.2 trillion in Federal funding between 2020 and
2026 to provide health insurance coverage and pay for direct medical
care for our citizens who are in poverty or who are at lower income
levels and cannot afford the full cost of their health insurance
coverage. Earlier this month, the Congressional Budget Office (CBO)
released its most comprehensive look at health insurance coverage and
spending since its March 2016 baseline.\1\ This report is useful in
understanding the context of the Graham-Cassidy-Heller-Johnson proposal
and the populations it would impact most significantly.
---------------------------------------------------------------------------
\1\ The Congressional Budget Office (CBO). ``Federal Subsidies for
Health Insurance Coverage for People Under Age 65: 2017 to 2027''
(September 2017). Available at: https://www.cbo.gov/system/files/115th-
congress-2017-2018/reports/53091-fshic.pdf.
Graham-Cassidy-Heller-Johnson would replace the private insurance
subsidies and Medicaid expansion funding provided under the Affordable
Care Act (ACA) with State block grants. CBO reports that 9 million
individuals are receiving subsidies to purchase individual coverage
through the marketplaces and coverage through the Basic Health Program
(BHP) in 2017. By comparison, that is about the same number of people
the CHIP program has covered in the past several years and is less than
3 percent of the total population in the United States under age 65.
The second population group included in the block grant proposal is the
13 million adults who are now covered through Medicaid at a State
option. Thus, coverage for this population is already administered by
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States.
In scoring H.R. 3590, the Patient Protection and Affordable Care
Act (PPACA) \2\ CBO estimated that under ``current law'' there would be
35 million nonelderly people enrolled in Medicaid and CHIP in 2017, 5
million fewer than the number of people enrolled in 2010 (CBO Director
Douglas Elmendorf letter to Majority Leader Harry Reid, March 11,
2010).\3\ Conversely, CBO projected that under PPACA (which would have
required all States to expand Medicaid), there would be 15 million more
people covered by Medicaid and CHIP in 2017 than under its current law
baseline. Today, there are 69 million nonelderly people enrolled in
Medicaid and CHIP, 13 million of whom are ``newly eligible'' adults.
Excluding the Medicaid expansion population, CBO projected there would
be 35 million people enrolled in Medicaid and CHIP in 2017. Instead,
there are 56 million people enrolled in Medicaid and CHIP (excluding
the Medicaid expansion)--21 million more people than CBO expected if
all States had expanded the program. That difference alone is twice the
size of the population receiving premium subsidies this year.
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\2\ PPACA was passed by the Senate on December 24, 2009. The Health
Care and Education Reconciliation Act of 2010 made additional changes
to PPACA. Together, the two Acts are commonly referred to as the
Affordable Care Act (ACA).
\3\ https://www.cbo.gov/sites/default/files/cbofiles/ftpdocs/113xx/
doc11307/reid_letter_hr359
0.pdf, Table 3.
Experience now tells us what CBO could not accurately model back in
2010, that there is very different distribution in the sources of
coverage for individuals with income at lower income levels than
expected. As Congress searches for answers for how to stabilize
premiums for those in the individual market, it should consider where
people actually went for coverage. Millions of people CBO expected to
enroll in the individual market are in Medicaid instead. Combining
funding for these two groups into State block grants is consistent with
the basic concepts of insurance pools. Adding younger, healthier lives
and spreading the risk among a larger pool of people will help
stabilize premiums for everyone in the individual market, both those
---------------------------------------------------------------------------
who are subsidized and those who are not.
Creating a new program to cover 22 million people beginning in 2020
will be a challenge for States, but is not unrealistic. States are
already serving more than half of these individuals through Medicaid;
and there are 50 million more people under age 65 covered through
traditional Medicaid. States administer the Supplemental Nutrition
Assistance Program (SNAP) on behalf of the Federal Government.
Enrollment in SNAP has ranged from 47.4 million people in October 2013
to 41.3 million people in June 2017.\4\ So as you consider this new
grant program to be administered by the States, it would be a program
of relatively modest size. Additionally, using the Modified Adjusted
Gross Income (MAGI) methodology to determine eligibility is much easier
to administer than the old Medicaid income standards and methodologies.
There should be no question as to whether States have the ability to
administer such a program.
---------------------------------------------------------------------------
\4\ https://fns-prod.azureedge.net/sites/default/files/pd/
34SNAPmonthly.pdf.
CBO estimates that, in 2020 under current law, the Federal
Government will spend a total of $147 billion to subsidize the cost of
---------------------------------------------------------------------------
coverage:
$82 billion for the newly eligible Medicaid population;
$49 billion for premium tax credits;
$10 billion for cost sharing reduction outlays; and
$6 billion for the Basic Health Program (which provides coverage
to 1 million people).
Graham-Cassidy-Heller-Johnson appropriates an amount nearly equal
to the CBO projections ($146 billion in 2020) for the States and gives
States 3 years to spend their annual allotments. It also allows States
to use 15 percent of their funds (20 percent with a waiver) to provide
services to Medicaid populations. There is an additional appropriation
of $15 billion in 2020 that the Administrator of the Centers for
Medicare and Medicaid Services (CMS) can use to provide short-term
assistance to carriers or States to help stabilize the markets.
In 2017, the Federal Government will spend about $111 billion on
the Medicaid expansion population and private insurance subsidies,
according to the September 2017 CBO report. Under the Graham-Cassidy-
Heller-Johnson proposal, Federal spending for these populations will
increase to $190 billion in 2026, an increase of more than 70 percent.
Slowing the rate of growth should not be considered a ``loss'' to the
States or to individuals. For example, in its March 2015 Medicaid
baseline, CBO projected that the average Federal spending on benefit
payments per elderly enrollee would be $10,620 in 2017. In January
2017, CBO revised its estimate that the average Federal spending on
benefit payments per elderly enrollee would be $8,000 in 2017. CBO also
reduced its average per enrollee spending estimate for the Medicaid
blind and disabled population for 2017 from $14,310 to $12,150. I am
not aware of an argument among policymakers that the elderly Medicaid
population ``lost'' $2,620 in benefits or that people with disabilities
``lost'' more than $2,000 in benefits. Growth in average spending has
simply been slower than previously projected.
chip as the model and platform
Twenty years ago, Chairman Hatch provided the leadership necessary
to create the State Children's Health Insurance Program under title XXI
of the Social Security Act. Senator Grassley was also a member of the
Senate Finance Committee at that time and helped shape this new
program, which serves about 8 million children today at a cost of
approximately $16 billion this year. The original features of the CHIP
program included:
Capped allotments to States;
Great flexibility given to States to determine eligibility,
benefits, and cost sharing;
A mandatory appropriation for a limited number of years; and
No individual entitlement.
One of the stated goals of the ACA was to lower the cost of health
care, but the law has fallen far short in achieving this aim. The
Graham-Cassidy-Heller-Johnson proposal provides a mechanism for the
Federal Government to incentivize the States to succeed where current
law has not. States will react to the new budget caps in the same
manner as they did to CHIP--by designing the program in a manner that
spreads the dollars in the most effective and economical manner
possible while staying within the constraints of a fixed budget.
Adopting CHIP as the model and platform should be viewed as a very
positive advantage for the Graham-Cassidy-Heller-Johnson proposal.
There are already policies and procedures in place to handle financial
transactions between the Federal Government and States. States have an
existing accountability system to modify rather than build from the
bottom up. Over the 20-year history of CHIP, Congress has consistently
reauthorized the program, and periodically increased funding for it.
Indeed, Chairman Hatch and Ranking Member Wyden have recently announced
their agreement to reauthorize CHIP for another 5 years.
allotment formula under graham-cassidy-heller-johnson
When CHIP was created, nothing like it existed on a national level.
Only three States had started their own programs to serve low-income
children. Congress constructed a funding formula out of necessity based
on several variables, including the number of low-income children
without health insurance. Congress also tried to create greater equity
among the States through the enhanced match rates it would pay them.
Today's situation is quite different. The Graham-Cassidy-Heller-
Johnson formula starts with the current distribution of funding among
the States. Because not all States expanded Medicaid eligibility under
PPACA, the distribution of funds varies greatly. Over time, this
proposal seeks to distribute funds on a more equitable basis so that,
by 2026, per capita Federal funding is spread evenly among the States.
There is no perfect funding formula that can accommodate all the
variations among States and that includes the match rate formula for
determining the Federal Medical Assistance Percentage (FMAP) used in
the Medicaid program. Every State can give a multitude of reasons as to
how it is disadvantaged. The goal of achieving financial parity is
laudable. The proposal makes those adjustments gradually, over a period
of 8 years from now.
medicaid per-capita caps
While the Graham-Cassidy-Heller-Johnson proposal offers an entirely
new approach to providing coverage for the newly eligible Medicaid
adults and subsidized private insurance enrollees, the proposed per-
capita cap concept for the traditional Medicaid population is familiar.
The discussion on per-capita caps is even older than CHIP.
The legislative language on per-capita caps is complex, as there
are exclusions from the caps, a formula for setting the base rates by
population group, and different growth rates among the population
groups. The caps apply only to per-capita Federal funding of benefits,
not to enrollment growth.
Per-capita caps are not new to Medicaid. States, including
Arkansas, have accepted per-capita spending caps in their various
section 1115 Demonstration Projects. States are at full risk for any
cost greater than these caps. These caps typically have some inflation
protection, which Graham-Cassidy-Heller-Johnson also includes.
The success of per-capita caps in controlling growth rates through
section 1115 demonstration projects is ample evidence to apply them to
the traditional Medicaid program. However, per-capita caps have been an
option for States. And few States have accepted per-capita caps for
their most expensive populations--the elderly and people with
disabilities. This is the area in which CMS must be willing to give
States ample authority to use new approaches to service delivery
reform. Risk is only acceptable when States have the authority to
control how services are delivered.
States learn and borrow from each other. No doubt there will be an
accelerated learning curve for some. The good news is many States,
including Arkansas, are ahead of the curve with new models of organized
care.
Per-capita caps, without a doubt, are a means of imposing fiscal
discipline, and there is no escaping that fact. We also know that
Medicaid is unsustainable for both the States and the Federal
Government, and the hard work needs to be done.
work requirements
Graham-Cassidy-Heller-Johnson includes an option for the States to
adopt a work requirement for able-bodied adults on Medicaid. Work
requirements are consistent with the original purpose of Medicaid
expressed in section 1901, which includes, ``. . . to help such
families and individuals attain or retain capability for independence.
. . .'' Medicaid can help working aged adults, on a temporary basis, to
improve their health and get back on their feet. But the safety net
should not be a restraint that deters someone from fully participating
in the labor force and improving their economic standing.
Last month, Arkansas Works paid $524.32 in premiums, cost sharing,
and additional services for each of the 257,579 enrollees in a
qualified health plan (QHP), which equals nearly $6,300 per year per
individual. Approximately 60,000 of these adults had income above the
poverty level ($12,060 for a single adult) and were required to pay
about $13 a month for their health insurance premiums, plus up to $3
for each drug prescription. The able-bodied adults with income below
100 percent of poverty paid nothing for their coverage.
We have asked CMS for approval to impose mandatory work
requirements on certain able-bodied adults that would be enforced by
loss of coverage if the adult does not comply for more than 3 months in
a calendar year. On a bipartisan basis, our State legislators agreed
that expecting able-bodied adults to work in exchange for $6,300 in
health insurance coverage benefits is fair. Legislators across the
political spectrum supported the Governor in a special legislative
session earlier this year to reinforce the message that the pathway to
independence is through work.
If our waiver request is approved, beginning January 1, 2018, those
with income below 100 percent of poverty will be required to either
work or engage in one of several activities, such as going to school,
participating in job training, or volunteering. Achieving that
objective will help lift people in our State out of poverty. Our design
also exempts about half of the Arkansas Works population for a variety
of reasons, including those who already work at least part time or are
caring for a child or disabled family member. Additionally, the
requirement will apply only to individuals less than 50 years of age.
Work requirements present opportunities to learn new skills,
broaden horizons, overcome new challenges, experience the intrinsic
dignity of work, build for the future, and give back to the community.
The benefits of work are far greater than earning a paycheck. Work
leads to independence, which is among the core objectives of the
Medicaid program. Thus, our focus on promoting work goes beyond the
Arkansas Works program. For instance, we recently redesigned our home
and community-based services waiver for people with developmental and
intellectual disabilities to emphasize community-supported employment
because of this population's ardent aspirations for the experience of
work.
Work requirements are a fair bargain in the social contract between
individuals on public assistance and the taxpayers who foot the bill.
It is important to examine the relationship in a new light in which the
cost of coverage to the taxpayer is recognized as a true value by the
person covered. The able-bodied adults have an obligation to their
neighbors meet the requirements of the program. Rights cannot be
separated from responsibilities. The Department of Human Services
(DHS), the Department of Workforce Services (DWS), health insurance
carriers, State and local educational agencies, and private sector
partners will assist individuals in meeting their work requirement. The
message to these individuals is that there are people willing to help,
but you must also be willing to help yourself.
Creating the expectation of work has already demonstrated some
success. Since January 1, 2017, Arkansas Works recipients have been
referred to DWS. More than 15,000 Arkansas Work recipients started new
jobs without accessing any DWS services. Over 8,600 individuals
accessed at least one DWS service and, of these, 1,361 have started new
jobs. With the new waiver, Medicaid coverage for adults will become
more than just access to medical services. It will present new hope as
a pathway out of poverty and to greater prosperity for individuals,
their families, their communities, and our State. The new work
requirements are not only about today, they are about the future.
conclusion
Governor Hutchinson has joined more than a dozen other Governors in
lending their strong support to the Graham-Cassidy-Heller-Johnson
solution. Working with the Arkansas Delegation, other Governors,
administration officials, and Senators Graham, Cassidy, and Santorum,
changes have been made to improve this approach over the past several
weeks. It is my pleasure to convey his strong support to the committee.
______
Prepared Statement of Dick Woodruff, Senior Vice President of Federal
Advocacy, American Cancer Society Cancer Action Network
Good afternoon, Chairman Hatch, Ranking Member Wyden, and members
of the committee. My name is Dick Woodruff, Senior Vice President for
Federal Advocacy of the American Cancer Society Cancer Action Network
(ACS CAN). I appreciate the opportunity to testify today on behalf of
cancer patients and other patients living with chronic diseases on the
proposal introduced by Senators Lindsey Graham (R-SC) and Bill Cassidy
(R-LA) to repeal and replace the current health-care law. ACS CAN, the
nonprofit, nonpartisan advocacy affiliate of the American Cancer
Society, supports evidence-based policy and legislative solutions
designed to eliminate cancer as a major health problem. As the Nation's
leading advocate for public policies that are helping to defeat cancer,
ACS CAN ensures that cancer patients, survivors, and their families
have a voice in public policy matters at all levels of government.
We recognize that the current health care law requires bi-partisan
fixes. But we oppose the Graham-Cassidy bill because of the potential
negative impact it would have on the 1.6 million Americans who will be
diagnosed with cancer this year \1\ and the additional 15.5 million
Americans living today with a history of cancer.\2\ For these
Americans--many of your own constituents--access to affordable health
insurance is a matter of life or death. Research from the American
Cancer Society has shown that uninsured Americans are less likely to
get screened for cancer and thus are more likely to have their cancer
diagnosed at an advanced stage when survival is less likely and the
cost of care more expensive.\3\
---------------------------------------------------------------------------
\1\ American Cancer Society, ``Cancer Facts and Figures 2017,''
available at https://www.
cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/
annual-cancer-facts-and-figures/2017/cancer-facts-and-figures-2017.pdf.
\2\ Id.
\3\ E. Ward et al., ``Association of Insurance With Cancer Care
Utilization and Outcomes,'' CA: A Cancer Journal for Clinicians 58:1
(Jan./Feb. 2008), http://www.cancer.org/cancer/news/report-links-
health-insurance-status-with-cancer-care.
---------------------------------------------------------------------------
the graham-cassidy bill could gut pre-existing condition protections
For many years, a cancer diagnosis made it nearly impossible to get
or keep insurance for Americans who relied on private health insurance
sold in the individual and smaller group markets. Prior to enactment of
the current law, health insurers in most States that sold in those
markets could refuse to cover an individual with a pre-existing
condition like cancer; could limit and/or refuse to cover care
associated with a pre-existing condition; or could charge a higher
premium based on pre-existing conditions--making insurance
unaffordable. A survey conducted before passage of the current law
found that 36 percent of those who tried to purchase health insurance
directly from an insurance company in the individual insurance market
were turned down, charged more, or had a specific health problem
excluded from their coverage.\4\ Some people even found their insurance
policies rescinded after being diagnosed with cancer. The current law
prohibits these discriminatory practices and has helped to ensure that
millions of people with serious illnesses like cancer can get and keep
their coverage.
---------------------------------------------------------------------------
\4\ M.M. Doty, S.R. Collins, J.L. Nicholson, et al., ``Failure to
Protect: Why the Individual Insurance Market is not a Viable Option for
Most U.S. Families.'' The Commonwealth Fund, July 2009.
Unfortunately, the Graham-Cassidy proposal essentially rolls back
the non-discrimination protections in the individual and small group
market. Although the bill would technically prohibit plans from denying
individuals coverage due to pre-
existing conditions, it would allow States to waive the requirement
that prohibits health plans from considering an individual's health
history when determining premiums. For an individual in active cancer
treatment or a cancer survivor, the health plan could have no limit on
the amount of the monthly premium. Products would be unaffordable to
individuals who required--or were anticipated to require--high-cost
---------------------------------------------------------------------------
treatments.
The bill would also allow States to waive some or all of the
essential health benefits (EHBs) requirements. Insurance should cover
the major health needs of cancer patients and survivors, including
hospitalization, specialty cancer care, physician services,
prescription drugs, rehabilitative care, screenings, and mental health
services. Eliminating EHB requirements would encourage insurers to
streamline ``basic'' policies that do not include explicitly defined
comprehensive benefits, thus putting cancer patients and survivors at
risk of inadequate treatment, and could jeopardize access to necessary
preventive care, treatment, and follow-up care.
Moreover, since the current law ties the prohibition on lifetime
and annual benefit limits to the EHB requirements, by eliminating the
EHB requirements, the
Graham-Cassidy proposal could also eliminate these other important
protections. Health plans could once again impose lifetime or annual
limits on benefits provided to enrollees, increasing the chances that a
diagnosis of cancer or other serious condition could lead to severe
financial hardships for many Americans.
Finally, the legislation would allow States to waive the current
three-to-one age rating requirements that limit what insurers can
charge in premium on the basis of the age of the enrollee. While cancer
can be diagnosed at any age, the incidence of cancer increases with
age. According to the American Cancer Society, 85 percent of all
cancers in the United States are diagnosed in people 50 years of age
and older.\5\ Thus, increasing the age rating bands would mean that
older individuals (those more at risk of developing cancer) would face
significantly higher health-care premiums or be priced out of the
market completely. Prior to the enactment of the current laws age
rating band restrictions, older adults faced significant problems
accessing health insurance coverage, in large part because insurers in
many States were permitted to charge older enrollees many times what
they charged younger ones, (compounded by the ability of issuers to use
health status when setting premiums).\6\
---------------------------------------------------------------------------
\5\ American Cancer Society, ``Cancer Facts and Figures 2017.''
\6\ Gerry Smolka, Leigh Purvis, and Carols Figueiredo, ``Health
Care Reform: What's at Stake for 50- to 64-Year-Olds,'' AARP Public
Policy Institute, Insight on the Issues #124, March 2009.
the graham-cassidy bill could make coverage unaffordable
The legislation provides that, beginning in 2020, individuals would
no longer qualify for Federal tax credits or subsidies. Instead, States
would receive a block grant of Federal funds intended to cover the
State's portion of Advance Premium Tax Credits (APTCs), Cost-Sharing
Reduction subsidies (CSRs), Medicaid expansion funds, and funds from
the Basic Health Insurance program.
States could use these funds to implement their own insurance
programs and the coverage could vary significantly by State.
Unfortunately, compared to CBO projections of current law spending,
funds available under the block grants would be substantially below the
amounts that would be available for Medicaid and health insurance
subsidies under current law, shortchanging States and almost
guaranteeing that the level of subsidies will not be maintained.
Further, the legislation is silent regarding any consumer
protections that a State should implement in designing their individual
State insurance program. There are no requirements that a State
maintain the same level of subsidies for individuals, thus leaving
individuals vulnerable to higher out-of-pocket costs under the Graham-
Cassidy bill than would be incurred under current law. Compared to
Congressional Budget Office projections of current law spending, the
funds that would be made available under the block grants are
substantially below the amounts that would be available for Medicaid
and health insurance subsidies under current law, shortchanging States
and almost guaranteeing that the level of subsidies will not be
maintained.
In addition, the block grant is only available to States until the
end of 2026, after which the block grant is eliminated leaving the
States to shoulder 100 percent of the cost of administering their
health insurance program. With Federal funds eliminated, it is likely
that any State program enacted under Graham-Cassidy would be either
severely curtailed or eliminated entirely, depending on the State
budget.
the graham-cassidy bill would significantly cut medicaid
Medicaid is the health insurance safety-net for lower income
Americans, offering quality, affordable, and comprehensive health care
coverage to over 74 million people \7\--including those with cancer,
those who will be diagnosed with cancer, and cancer survivors. Medicaid
provides important preventive screenings and treatment services for
cancer patients and survivors. It is projected that in 2017,
approximately 2.3 million patients (infants to age 64) with cancer or a
history of cancer will rely on Medicaid and the Children's Health
Insurance Program (CHIP) for their insurance--a 31 percent increase
from 2013.\8\ Out of the 2.3 million enrollees, 540,000 are estimated
to be receiving Medicaid coverage under the current law's Medicaid
expansion. Additionally, Medicaid provides coverage for children--with
approximately one-third of pediatric cancer patients enrolled in
Medicaid at the point of diagnosis.\9\
---------------------------------------------------------------------------
\7\ Medicaid.gov. June 2017 Medicaid and CHIP enrollment data
highlights. Accessed September 18, 2017. https://www.medicaid.gov/
medicaid/program-information/medicaid-and-chip-enrollment-data/report-
highlights/index.html. Note: Numbers include both Medicaid and
Children's Health Insurance Program (CHIP) enrollment.
\8\ Analysis provided to ACS CAN by Avalere Health. Funding for
Medicaid patients with cancer under BCRA Discussion Draft. Analysis
performed June 2017.
\9\ Id.
The Graham-Cassidy bill would significantly cut funding for
Medicaid. The bill would end the expansion of Medicaid by 2020 and
reduce Medicaid funding for the traditional Medicaid population--
including seniors, people with disabilities, and low-income families
with children--by imposing a per-capita cap. The cap could potentially
---------------------------------------------------------------------------
limit enrollment and services.
The proposed repeal of Medicaid expansion along with significant
Federal funding changes could leave the Nation's lowest income cancer
patients and survivors without access to preventive, curative, and
follow-up health care, as States struggle to decide how to manage their
Medicaid populations with less Federal dollars. For low-income
Americans, the changes proposed by Graham-Cassidy could be the
difference between an early diagnosis when outcomes are better and
costs are less or a late diagnosis where costs are higher and survival
less likely.
the graham-cassidy time frame is unworkable
Under the legislation States would be required to create a new
program for their individual health insurance market within 2 years.
The creation and implementation of new mechanisms for providing
coverage and revising State insurance rules will require a significant
investment in terms of time and resources from State governments and,
in many cases, may require enactment of State laws and/or regulations.
Many State legislatures are already out of session and are not slated
to return until the beginning of next year, which would leave little
time for a State to have a meaningful opportunity for input before
enacting its new marketplace.
Moreover, the changes to the health insurance individual market
called for under the Graham-Cassidy proposal would require significant
education and outreach to consumers. Because these programs would be
administered at the State level, the same State agencies that are
responsible for creating and implementing their marketplace would also
be tasked with consumer education and outreach, putting additional
strain on these already overly burdened entities.
moving forward
For the reasons previously stated, ACS CAN is opposed to the
Graham-Cassidy legislation and urges the committee to reject the
legislation. At the same time, we recognize that the current law will
require additional fixes.
We commend the bipartisan efforts of Senators Alexander and Murray
as they work through regular order to find bipartisan solutions that
benefit patients. Such a process must ensure that individuals with pre-
existing conditions are protected, that essential health benefits are
maintained, and that coverage is made affordable for individuals. We
urge this committee to build upon their work and focus on practical,
bipartisan efforts to strengthen health-care coverage.
ACS CAN stands ready to work with the committee and all members of
Congress to develop and implement policies that will improve the
health-care system for the millions of individuals who are in active
cancer treatment and cancer survivors.
______
Questions Submitted for the Record to Dick Woodruff
Questions Submitted by Hon. Ron Wyden
pre-existing conditions
Question. During the hearing on September 25th, Senator Cassidy
stated the following regarding the protection of those with pre-
existing conditions: ``The statute specifically says that the Governor
must establish that those with pre-existing conditions have access to
`adequate and affordable' coverage.'' He also stated on September 20th
on CNN: ``We protect those with pre-existing conditions. . . . The
protection is absolutely the same. There's a specific provision that
says that if a State applies for a waiver, it must ensure that those
with pre-existing conditions have affordable and adequate coverage.''
He has made this claim that those with pre-
existing conditions would be protected under his law to the same extent
that they are under current law several times.
Do you agree with Senator Cassidy that those with cancer or other
conditions would have the same protections as under current law?
Answer. Cancer patients would not have the same protections that
they have under current law. The Graham-Cassidy proposal rolls back the
non-discrimination protections in the individual and small group
market. It would allow States to waive the current-law requirement that
prohibits health plans from considering an individual's health history
when determining premiums. For an individual in active cancer treatment
or a cancer survivor, the health plan could have no limit on the amount
of the monthly premium. Products would be unaffordable to cancer
patients and other individuals who required--or were anticipated to
require--high-cost treatments.
The Graham-Cassidy bill would also allow States to waive some or
all of the essential health benefits (EHBs) requirements. Insurance
should cover the major health needs of cancer patients and survivors,
including hospitalization, specialty cancer care, physician services,
prescription drugs, rehabilitative care, screenings, and mental health
services. Eliminating EHB requirements would encourage insurers to
create ``basic'' policies that do not include explicitly defined
comprehensive benefits, thus putting cancer patients and survivors at
risk of inadequate treatment, and could jeopardize access to necessary
preventive care, treatment, and follow-up care.
In addition, current law ties the prohibition on lifetime and
annual benefit limits to the EHB requirements, by eliminating the EHB
requirements, the Graham-
Cassidy proposal could also eliminate these other important
protections. Health plans could once again impose lifetime or annual
limits on benefits provided to enrollees, increasing the chances that a
diagnosis of cancer or other serious condition could lead to severe
financial hardships for many Americans.
Finally, the legislation would allow States to waive the current
three-to-one age rating requirements that limit what insurers can
charge in premiums on the basis of the enrollee's age. While cancer can
be diagnosed at any age, the incidence of cancer increases with age.
According to the American Cancer Society, 85 percent of all cancers in
the United States are diagnosed in people 50 years of age and older.
Thus, increasing the age rating bands would mean that older individuals
(those more at risk of developing cancer) would face significantly
higher health-care premiums or be priced out of the market completely.
Prior to the enactment of the current law's age rating band
restrictions, older adults faced significant problems accessing health
insurance coverage, in large part because insurers in many States were
permitted to charge older enrollees many times what they charged
younger ones, (compounded by the ability of issuers to use health
status when setting premiums).
Question. What do you believe would be the impact of this law on
cancer patients' and survivors' ability to access and afford needed
care?
Answer. Graham-Cassidy could negatively impact the 1.6 million
Americans who will be diagnosed with cancer this year and the
additional 15.5 million Americans living today with a history of
cancer. For these Americans access to affordable health insurance is a
matter of life or death. Research from the American Cancer Society has
shown that uninsured Americans are less likely to get screened for
cancer and thus are more likely to have their cancer diagnosed at an
advanced stage when survival is less likely and the cost of care more
expensive.
We are deeply concerned that cancer patients and other patients
would lose their insurance if the Graham-Cassidy legislation is
enacted. If States elect to make available policies without EHB
requirements, protection against annual and lifetime caps could be
eliminated because the caps are tied to those benefits. Insurers could
be allowed to segment the risk pool by pricing high-risk patients out
of the market. Insurers could be allowed to offer plans that don't
cover the treatment or all the services that seriously ill patients or
survivors of cancer need. The plan they need may not even be offered,
or it may be too expensive for any of them to afford.
Again, we know that patients without coverage have their cancers
discovered later, they are more expensive to treat, and they have lower
chance of survival. They forego preventive care, they choose between
doctor-recommended treatments because they can't afford everything
they're supposed to have. Their medical costs force them into debt and
sometimes into bankruptcy. If enacted, the Graham-
Cassidy legislation would be a disaster for patients with cancer,
survivors of cancer, and other Americans with serious illness.
Question. Prior to the ACA, what was the impact of annual and
lifetime caps on cancer patients?
Answer. Prior to the enactment of the ACA cancer patients and
survivors were often affected by annual and/or lifetime benefit caps
which limited their benefits and thus their ability to access needed
and recommended treatment and other health-care benefits. These caps
were the norm in the individual and small group markets, but also
existed is some employer based plans as well affecting millions of
Americans. The ACA, by requiring qualified plans to cover 10 specific
Essential Health Benefits and abolishing caps on those benefits,
effectively made sure that insurance actually covers Americans when
they get sick without an arbitrary monetary cap on their care.
Among the many patient stories reported to the American Cancer
Society in 2010 about the inequity of benefit caps, was the experience
of the 10 year-old leukemia patient from Ohio who had reached the $1
million lifetime benefit cap imposed on her father's employer-based
health-care plan. This family was forced to delay their daughter's hip
surgery, which was necessitated by the side effects of her cancer
treatment. At the time ACS learned of her condition, she was confined
to a wheelchair while her family searched for alternative ways to
finance her surgery.
No family in America expects their child to be diagnosed with a
serious disease like cancer. But the experience of this young girl was
not unique. Americans with serious and chronic illnesses routinely
exhausted their limited benefits which severely impacted their ability
to access needed health care. Elimination of the caps by the ACA ended
that terrible situation.
______
Questions Submitted by Hon. Sherrod Brown
Question. Creating thoughtful, responsible, and effective
legislation requires the input of diverse subject matter experts,
representing different stakeholder communities. The Graham-Cassidy
proposal is a remake of the entire U.S. health-care system, which
necessitates input from groups like advocacy organizations,
professional societies, or other reputable associations.
Were you or representatives of the American Cancer Society Cancer
Action Network or other advocacy organizations you work with, consulted
on this legislation?
Answer. The American Cancer Society Cancer Action Network (ACS CAN)
was pleased to be invited to testify about the legislation before the
Finance Committee on September 25th. Prior to that event, however,
neither I nor anyone employed by ACS CAN, received any communication or
consultation, or request for such, from the authors of the legislation
or their staffs. I can't speak with complete knowledge about the extent
of consultation by the authors with other advocacy organizations we
work with, but my understanding is that there was none.
Question. Are you convinced that individuals with preexisting
conditions will be protected under this bill?
Answer. No, individuals with preexisting conditions will not be
protected under the Graham-Cassidy legislation. I'll take the liberty
of repeating my response to a similar question asked by Senator Wyden.
Cancer patients would not have the same protections that they have
under current law. The Graham-Cassidy proposal rolls back the non-
discrimination protections in the individual and small group market. It
would allow States to waive the current-law requirement that prohibits
health plans from considering an individual's health history when
determining premiums. For an individual in active cancer treatment or a
cancer survivor, the health plan could have no limit on the amount of
the monthly premium. Products would be unaffordable to cancer patients
and other individuals who required--or were anticipated to require--
high-cost treatments.
The Graham-Cassidy bill would also allow States to waive some or
all of the essential health benefits (EHBs) requirements. Insurance
should cover the major health needs of cancer patients and survivors,
including hospitalization, specialty cancer care, physician services,
prescription drugs, rehabilitative care, screenings, and mental health
services. Eliminating EHB requirements would encourage insurers to
streamline ``basic'' policies that do not include explicitly defined
comprehensive benefits, thus putting cancer patients and survivors at
risk of inadequate treatment, and could jeopardize access to necessary
preventive care, treatment, and
follow-up care.
In addition, current law ties the prohibition on lifetime and
annual benefit limits to the EHB requirements, by eliminating the EHB
requirements, the Graham-
Cassidy proposal could also eliminate these other important
protections. Health plans could once again impose lifetime or annual
limits on benefits provided to enrollees, increasing the chances that a
diagnosis of cancer or other serious condition could lead to severe
financial hardships for many Americans.
Finally, the legislation would allow States to waive the current
three-to-one age rating requirements that limit what insurers can
charge in premium on the basis of the age of the enrollee. While cancer
can be diagnosed at any age, the incidence of cancer increases with
age. According to the American Cancer Society, 85 percent of all
cancers in the United States are diagnosed in people 50 years of age
and older. Thus, increasing the age rating bands would mean that older
individuals (those more at risk of developing cancer) would face
significantly higher health-care premiums or be priced out of the
market completely. Prior to the enactment of the current laws age
rating band restrictions, older adults faced significant problems
accessing health insurance coverage, in large part because insurers in
many States were permitted to charge older enrollees many times what
they charged younger ones, (compounded by the ability of issuers to use
health status when setting premiums).
______
Prepared Statement of Hon. Ron Wyden,
a U.S. Senator From Oregon
Nobody has to buy a lemon just because it's the last car on the
lot. The Graham-Cassidy bill is a health-care lemon; a disaster in the
making. The fact that it's the last Republican repeal plan standing
doesn't make it acceptable. It'll be a nightmare for tens of millions
of Americans. It makes a mockery of the Trump promises of better
insurance for everybody at much lower costs.
This bill's sponsors aren't even waiting for the official facts and
figures from the independent scorekeepers. Version after version after
version of the bill is floating around, and the pork parade is up and
running. The process that has brought
Graham-Cassidy to the brink of passage would be laughable if the well-
being of tens of millions of Americans wasn't hanging in the balance.
I want to blow the whistle on a few key points right at the outset
of today's hearing. First off, the American people do not want this
bill. In the last few days, the committee has received more than 25,000
comments from people who want it stopped. As with every other version
of Trumpcare, this proposal is about as popular as prolonged root canal
work.
There's just one group cheering this bill on--the right-wing
Republican donor class. The big donors wanted the entire ACA thrown in
the trash can from the beginning. But that didn't work, since it turns
out it's bad policy to take health coverage away from tens of millions
of Americans and raise costs for virtually everybody else.
So the new strategy you see in Graham-Cassidy is repeal by a
thousand cuts. It'll be national repeal and state-by-state repeal. The
heart of this bill is a scheme that punishes States that have worked
hard to build strong private markets and make health care more
affordable. It rewards the States where lawmakers have sat on their
hands--where they've spent years loudly rejecting the opportunity to
improve the lives of millions of the people they serve.
But that's obviously not a proposition that will garner much
support. So instead, what the committee will hear today is a lot of
hocus-pocus talk about ``flexibility.'' The story goes, it's
flexibility for the States, more control at the local level, and
everybody will somehow be better off. But let's be up-front about what
that'll mean in practice.
The real flexibility created by this bill is the option for States
to do worse--so that Americans are forced to pay more money for less
care.
Right off the top, Graham-Cassidy guts funding for health care in
its new block grants. Then, Governors and State legislators building
new health insurance systems will have to make Hunger Games choices,
deciding which vulnerable groups will get the care they need and which
will not.
The ironclad, loophole-free, guaranteed protection for those with
pre-existing conditions under the Affordable Care Act will be gone. The
bill's sponsors will tell you otherwise, but the facts are the facts.
The guaranteed protection that nobody will be gouged due to a
catastrophic illness like cancer will be gone. That's because this bill
reopens the door to annual and lifetime limits on care.
The guarantee of essential health benefits will be gone. That means
prescription drug coverage will be on the chopping block. Maternity
care will be on the chopping block. Mental health and substance abuse
treatment will be on the chopping block, along with much more. The
guarantee that nobody can be charged higher premiums because of their
health status or their job will be gone under this bill.
So bottom line, this bill is an attack on vital consumer
protections. It revives some of the worst insurance company abuses that
were banned under the ACA. And it will make the health care that many
people need unaffordable. So no, it does not protect people with pre-
existing conditions.
What this bill does include are a few toothless lines about
affordability and access. That's supposed to be enough to protect those
with pre-existing conditions. But there's no enforcement mechanism--no
tough standards or strict definitions. And the watered-down protections
that States put together for new insurance systems will get a rubber
stamp from Team Trump.
Once again in Graham-Cassidy, the attack on women's health
continues. Hundreds of thousands of women will lose the right to see
the doctors of their choosing--that's what happens when you defund
Planned Parenthood.
The traditional Medicaid program--which is a lifeline for people
with disabilities, seniors, kids and pregnant women--suffers draconian
cuts. An aging baby boomer who's suffered a stroke might be told they
can't get the help they need--nursing home care might no longer an
option for them. The community-based program that offers care to people
at home where they're most comfortable might disappear. Special
education programs funded by Medicaid for vulnerable kids could be put
in jeopardy.
A few final points. The process that's led to this moment has been
an abomination. What's happening this afternoon isn't a serious
hearing--it's a talking point. This is a scheme to allow Senators to go
home to fearful constituents and offer false reassurances that the
Graham-Cassidy bill got a fair examination and went through regular
order. But it won't be true.
Senate Republicans haven't gotten answers to the most basic
questions about the real-world effects of their bill. How many people
will lose coverage? By how much will premiums increase? Will health-
care markets survive next year? The independent scorekeepers at the
budget office have told us that it'll be several weeks before they can
put forward estimates of coverage and costs. And their job keeps
getting tougher. The bill is changing by the hour as the majority
throws around in the scramble for votes.
And why the rush job, you might ask. It's because the coach turns
back into a pumpkin at the end of the month. That's when the
reconciliation fast-track to pass this partisan bill expires.
Finally, this committee right now ought to be working on bipartisan
priorities, such as getting our CHIP bill over the finish line. There's
work to be done on stabilizing the private insurance markets, that
ought to be happening with our sister committee. Instead, what's on
offer with Graham-Cassidy would trigger a health-care disaster--a death
spiral in the insurance markets as tax credits and cost sharing
payments go away, as healthy people flee and costs go into the
stratosphere.
My Democratic colleagues and I have done and will continue to do
everything we can to stop this dreadful proposal in its tracks.
______
United States Senate
COMMITTEE ON FINANCE
Washington, DC 20510-6200
September 22, 2017
The Honorable Orrin Hatch
Chairman
Committee on Finance
U.S. Senate
Washington, DC 20510
Dear Chairman Hatch:
We respectfully request that the Finance Committee's September 25th
hearing on the Graham-Cassidy bill be held in one of the Senate's
larger hearing rooms rather than in our regular hearing room, Dirksen
215. This would be in keeping with the extraordinary importance of the
hearing and with the committee's usual practice with respect to matters
of such intense public interest.
The Graham-Cassidy bill would radically reshape the American health-
care system, and the Senate Finance Committee's hearing will be the
first and only opportunity for this bill to be debated in public before
it is due to be considered on the Senate floor. There is enormous
interest in the hearing, from the general public, groups representing
affected interests, and the press. We should do everything we can to
accommodate as many members of the public and the press as possible.
When considering the Affordable Care Act, the Senate Finance Committee
engaged in a bipartisan, collaborative process which included more than
50 hearings and roundtables and full 8 days marking up the legislation.
We engaged in this process because we believed our work should be
accountable to the American people. We also wanted the Affordable Care
Act to reflect a serious, carefully considered effort involving
stakeholder input and expert opinions, independent of ideology, because
we knew others had important contributions that would make the bill
stronger. While one hearing is better than none, this process reflects
none of the rigor that resulted in the passage of the Affordable Care
Act.
During consideration of the Affordable Care Act, the Senate Finance
Committee held multiple hearings in large meeting rooms, including Hart
216 and Dirksen 108. The committee held its 8-day markup, the longest
in committee history, in Hart 216. Additionally, the Health, Education,
Labor, and Pensions Committee recently held four hearings in Hart 216
that attracted significant attention from the media and press to
discuss a much narrower legislative objective.
Given that Monday's hearing will be the only venue for public debate on
the
Graham-Cassidy proposal, we feel it is appropriate that hearing be
moved to a larger Senate meeting room. We hope that you can accommodate
this modest request.
Sincerely,
Ron Wyden
Ranking Member
Committee on Finance
Debbie Stabenow Maria Cantwell
U.S. Senator U.S. Senator
Bill Nelson Robert Menendez
U.S. Senator U.S. Senator
Thomas R. Carper Benjamin L. Cardin
U.S. Senator U.S. Senator
Sherrod Brown Michael F. Bennet
U.S. Senator U.S. Senator
Robert P. Casey, Jr. Mark R. Warner
U.S. Senator U.S. Senator
______
United States Senate
COMMITTEE ON FINANCE
Washington, DC 20510-6200
September 25, 2017
The Honorable Orrin Hatch
Chairman
Committee on Finance
U.S. Senate
Washington, DC 20510
Dear Chairman Hatch:
We respectfully invoke our right, under Senate Rule XXVI, for a
majority of the minority members of the Finance Committee to call for
an additional day of hearings with respect to the Graham-Cassidy
proposal.
Today's hearing is the first hearing any Senate committee has held on
the
Graham-Cassidy bill or, for that matter, any previous version of bills
to ``repeal and replace'' the Affordable Care Act. A single hearing
does not give the committee, much less the public, sufficient time to
consider a major bill affecting one-sixth of the economy and the lives
of hundreds of millions of Americans. This is particularly the case
given that three different version of the bill have been released over
the past 24 hours.
This process contrasts sharply with the Finance Committee's process
during the consideration of the Affordable Care Act, when we held 11
days of hearings, followed by 8 days of markup during which 133
amendments were considered and 44 adopted, followed by 23 days of
debate on the Senate floor.
This call for additional witnesses is not intended to delay. We believe
that one or two panels of witnesses can be convened to testify
tomorrow, drawn from among groups representing patients, physicians,
nurses, hospitals, insurance companies, state program administrators,
the Congressional Budget Office, and health-care economists.
Thank you for attention to this matter.
Sincerely,
Ron Wyden
Ranking Member
Committee on Finance
Debbie Stabenow Claire McCaskill
Michael F. Bennet Sherrod Brown
Benjamin L. Cardin Robert P. Casey, Jr.
Maria Cantwell Mark R. Warner
Robert Menendez Thomas R. Carper
Bill Nelson
______
Communications
----------
Letter Submitted by Marilyn Adams
September 24, 2017
U.S. Senate
Committee on Finance
Dirksen Senate Office Building
Washington, DC 20510-6200
Re: Hearing to consider the Graham-Cassidy-Heller-Johnson proposal,
Monday, September 25, 2017
Dear Senator Hatch and members of the Senate Finance Committee:
I am writing to give my perspective on the Graham-Cassidy-Heller-
Johnson bill. I have been frankly amazed as I have watched Congress
repeatedly trying to slap together a bill and ram it through with
clearly little or no regard for discussion, review of the facts, a full
report from the CBO, etc. It seems obvious that your only goal is to
``repeal the ACA'' with zero regard for the actual impact your actions
will have on health care for the American people you have been elected
to represent.
I urge you to stop playing these games with our health and our lives,
slow down, and actually do the job you were elected to do. Please work
to find a solution that balances fiscal responsibility with the good of
the American people (your constituents) and take the time to get it
right. We will respect you for it and may even vote you back into
office.
I had hope when I heard there was a bipartisan group trying to develop
a plan together, and then all of a sudden here we are trying to shove
through yet another health-care bill at the last minute. I am guessing
most members of Congress don't even understand what is in the bill or
what impact it will have on their constituents. How could they possibly
understand it when we don't even have a full report yet from the CBO?
Please stop this nonsense and do the right thing! You were elected to
represent us, so please show some integrity and do the job you were
elected to do. I realize many of you do not know or understand this,
but people's lives are in your hands. Please don't blow it!
Respectfully,
Marilyn Adams
______
Alliance of Community Health Plans (ACHP)
1825 Eye Street, NW, Suite 401
Washington, DC 20006
p: 202-785-2247
f: 202-785-4060
https://www.achp.org/
September 22, 2017
U.S. Senate
Committee on Finance
Dirksen Senate Office Building
Washington, DC 20510-6200
On behalf of the 19 million Americans and the communities we serve, I
write to express our profound disappointment that bipartisan efforts to
stabilize our health-care system have been halted. The Graham Cassidy-
Heller-Johnson legislation being considered by the Senate would
jeopardize the health of millions of working Americans, and we cannot
support the bill.
Over the course of 2017, ACHP and its member plans have worked with
both houses of Congress and both sides of the aisle to put forward
measured and proven ways to expand coverage, stabilize the market and
make our nation's health-care system more affordable. ACHP members
believe in the importance of preventive and comprehensive care and have
consistently offered robust coverage, regardless of geographic location
or health status of their members.
This proposal would significantly impact the health of our communities,
hurting our neighbors, friends, and employees. It puts in jeopardy the
coverage gains won over the past few years and the critical consumer
safeguards provided by essential health benefits and protections
afforded by a ban on pre-existing conditions.
Millions of working Americans, many making an average of just $18,000
per year, would suffer under this bill from the loss of critical cost-
sharing reduction payments. While this debate is going on in
Washington, millions of Americans across the country are living month
to month wondering if they will have access to coverage this year or
next.
We are deeply troubled by the proposed changes to Medicaid. Graham-
Cassidy-
Heller-Johnson fundamentally erodes the Medicaid safety net and
significantly alters the gains in eligibility, coverage and benefits
achieved in almost every community nationwide, and does little to
mitigate the impact on local hospitals and economies.
While we support greater state flexibility, it is imperative that
capitation rates be actuarially sound and sufficient to ensure
beneficiary access to the full range of health-care services and a
stable Medicaid market. Further, it is critical that any health reform
effort harness the innovative and competitive market solutions driven
by the private sector. We fully support preserving the public-private
partnership unique to the American system.
We have supported the Senate HELP Committee as it worked to develop a
limited bipartisan bill that would stabilize the individual insurance
market. The health-care needs of Americans were well served by the
collaborative and inclusive way the hearings were held and the diverse
viewpoints aired during witness testimony. Health care should provide
Americans peace of mind. Rather than creating certainty in the lives of
the American people, Graham-Cassidy-Heller-Johnson takes us in the
opposite direction.
As always, ACHP member plans stand ready to work with you and members
of both parties to develop market-tested solutions based on our many
years of real-world experience to improve the health of communities
across the nation. If you or your staff have any questions or would
like to discuss these issues further, please do not hesitate to contact
me at [email protected] or 202-785-2247.
Sincerely,
Ceci Connolly
President and CEO
______
The ALS Association
1275 K Street, NW, Suite 250
Washington, DC 20005
www.alsa.org
On behalf of people living with ALS and their caregivers, The ALS
Association submits this statement for the record to oppose the
amendment to the American Health Care Act (ARCA) proposed by Senators
Lindsey Graham, Bill Cassidy, Dean Heller, and Ron Johnson.
The ALS Association, along with leading patient and provider groups,
opposes the Graham-Cassidy proposal because it does not meet our core
set of principles that health care must be accessible, affordable, and
adequate.
Amyotrophic lateral sclerosis (ALS) is a progressive neurodegenerative
disease that affects nerve cells in the brain and the spinal cord. The
progressive degeneration of the motor neurons in ALS patients leads to
disability and death of patients living with ALS--with an average life
span of 2 to 5 years after diagnosis. The prevalence of ALS in the
military is twice that of civilians.
The mission of The ALS Association is to discover treatments and a cure
for ALS, and to serve, advocate for, and empower people affected by ALS
to live their lives to the fullest. Affordable, adequate care is vital
to the patients we represent. Our Chapters work closely with Certified
Centers of Excellence that offer multidisciplinary ALS clinics as well
as provide a range of free services for people living with ALS and
their families including: support groups, care services coordinators,
equipment loan programs, assistive technology support, and respite care
grants. The ALS Association is a non-partisan organization that leads
the fight to treat and cure ALS through global research and nationwide
advocacy.
Unfortunately, the Graham-Cassidy proposal would negatively impact the
access of people living with ALS and many Americans to adequate and
affordable health coverage and care.
Patient Protections: First, it would undermine nationwide
protections for patients by offering states the ability to allow
insurance companies to charge higher prices and place limitations on
coverage (such as annual or lifetime caps) for those with preexisting
conditions.
Premium Assistance: Second, it would remove current premium
assistance to help lower-income and moderate income families to afford
to purchase the insurance that they need. This is especially important
for people living with ALS who lose their job and insurance coverage
after an ALS diagnosis but need to purchase health insurance for
themselves and their families. Without premium assistance, many of
these families could face serious financial stress or bankruptcy.
Medicaid: Third, it would dramatically cut access to Medicaid
health care by cutting and capping funds through block grants. Under
Graham-Cassidy, states would be forced to change eligibility to fit
their block grant funding or close enrollment in Medicaid when funds
run out. This impacts not only people living with ALS who depend solely
on Medicaid for coverage but also those patients who receive both
Medicare and Medicaid.
Veterans: Medicaid cuts would also harm veterans, as reported by
2017 research from the RAND Corporation, entitled ``Veterans' Health
Insurance Coverage under the Affordable Care Act and Implications of
Repeal for the Department of Veterans Affairs.'' Although many veterans
do receive health care through the Department of Veterans Affairs (VA),
a good number do not qualify or are unable to access VA care for a
number of reasons. The RAND report notes that Medicaid expansion and
marketplaces helped address gaps in health insurance coverage and
contributed to lower rates of un-insurance among veterans. This is
particularly important because the incidence of ALS in individuals is
much higher for those who have served in the military.
While we urge the Senate to reject Graham-Cassidy, we understand that
improvements to the current system are needed. We greatly appreciate
the bipartisan effort being spearheaded by Senators Alexander and
Murray. In hearings in the Senate Committee on Health, Education,
Labor, and Pensions, state regulators and governors of both parties
offered solutions to help stabilize the insurance market. We urge the
Finance Committee to join in these efforts to address issues within its
jurisdiction to develop bipartisan solutions to these complex issues.
In closing, we encourage Congress to reject the Graham-Cassidy proposal
because it will negatively impact people living with ALS who are part
of the 133 million Americans with chronic diseases and disabilities and
their family caregivers.
For More Information Contact:
Kathleen Sheehan, Vice President Public Policy
[email protected] (202) 591-5319
Stephen Goewey, Vice President Communications
[email protected] (202) 246-1619
______
ALS Association et al.
Contact: [email protected]
1150 Connecticut Avenue, NW
Washington, DC 20036
202-785-7900
Our organizations stand together in unified opposition to the
legislation being considered by the Senate Finance Committee today.
This proposal to overhaul our nation's health care system fails to
serve the needs of the millions of patients and consumers we represent.
A group of patient, provider, and consumer groups came together earlier
this year to engage with Congress in order to ensure that Members
understand how any legislation to repeal and replace the Affordable
Care Act would impact the individuals and families we represent. We
agreed that to gain our support, any proposal put forward must meet a
core set of criteria by providing care that is accessible, affordable,
and adequate. It is clear that the legislation before the Senate
Finance Committee today falls far short of meeting these standards and
would in fact do more harm than good. We stand united in opposition to
the proposal put forward by Senators Lindsey Graham (R-SC), Bill
Cassidy (R-LA), Dean Heller (R-NV), and Ron Johnson (R-WI) because of
the negative consequences it will have for patients' access to adequate
and affordable health care coverage.
This bill would drastically cut funding for the Medicaid program, roll
back important essential health benefit protections, reverse current
protections that ensure coverage for people with preexisting
conditions, open the door to lifetime caps on coverage, and endanger
access to critical care for millions of Americans. Much of the proposal
is just a repackaging of the most problematic provisions of the Better
Care Reconciliation Act (BCRA), which we also opposed.
On Friday, the Brookings Institution, a trusted independent and non-
partisan organization, released a report estimating that 21 million
fewer people will be covered from 2020-2026. This unprecedented loss of
coverage is completely unacceptable.
Affordable, adequate care is vital to the patients we represent and can
mean the difference between life and death. It is clear to our
organizations that this legislation fails to provide Americans with
what they need to maintain their health. Our organizations, instead,
strongly support improving our system of care through a rigorous and
transparent bipartisan legislative process. It is time for Congress to
put the interest of patients and consumers before politics. The Graham-
Cassidy proposal will have devastating impacts on those we represent
and we urge every member of the Senate to oppose this legislation.
ALS Association American Diabetes Association
American Heart Association American Lung Association
Arthritis Foundation Consumers Union
Crohns and Colitis Cystic Fibrosis Foundation
Epilepsy Foundation Family Voices
Lutheran Services in America March of Dimes
Muscular Dystrophy Association National Health Council
National Multiple Sclerosis Society National Organization for Rare
Disorders (NORD)
WomenHeart: The National Coalition
for Women With Heart Disease
______
American Academy of Family Physicians (AAFP)
1133 Connecticut Avenue, NW, Suite 1100
Washington, DC 20036-4305
(800) 794-7481
(202) 232-9033
September 25, 2017
The Honorable Orrin Hatch The Honorable Ron Wyden
Chairman Ranking Member
U.S. Senate U.S. Senate
Committee on Finance Committee on Finance
Washington, DC 20510 Washington, DC 20510
Dear Chairman Hatch and Ranking Member Wyden:
On behalf of the American Academy of Family Physicians (AAFP) and the
129,000 members we represent, I respectfully submit this letter to the
Senate Finance Committee to assist you and members of the Committee in
your evaluation and consideration of the Graham-Cassidy-Heller-Johnson
(GCHJ) proposal.
Thank you for holding this hearing and providing an opportunity for
organizations, such as the AAFP, to share with the Committee our views,
opinions, and recommendations on the GCHJ proposal and our current
health-care system.
The AAFP has significant concerns with the Graham-Cassidy-Heller-
Johnson bill and the negative impact it would have on individuals,
families, and our health-care system overall. The changes proposed by
GCHJ, according to numerous independent and non-partisan organizations,
would result in millions of currently insured individuals losing their
health-care coverage. Furthermore, it would destabilize insurance
markets, allow for discrimination against people based on their health
conditions, rollback vital insurance and consumer reforms, cause
increased premiums and deductibles for individuals and families, and do
nothing to reduce the costs of health care. For these reasons, we
oppose the Graham-Cassidy-Heller-Johnson proposal.
We urge the Senate to set aside efforts to repeal the ACA and focus on
improving current law in ways that expand access to affordable
coverage, reconnect patients back to primary care, stabilize insurance
markets, and begin to lower health-care costs.
Sincerely,
John Meigs, Jr., M.D., FAAFP
Board Chair
Background
The AAFP first adopted a policy on health-care coverage for all in
1989. Research shows that the two most telling factors indicative of
individual health is health-care coverage and a continuous relationship
with a primary care physician. Individuals who have a long-term,
continuous relationship with a physician, tend to be healthier and have
lower health-care costs per capita than those who lack such a
relationship. A key to establishing and maintaining a long-term
relationship with a physician is continuous health-care coverage.
The GCHJ proposal, in its current form, is not consistent with AAFP
policies on health-care coverage and, in our opinion, falls well short
of achieving our goal of ensuring that every American has health-care
coverage and improved and affordable access to a family physician.
The AAFP recognizes that current law and our current health-care system
has flaws and is failing to achieve some of our shared goals,
especially those aimed at slowing the escalating costs of health care.
However, we also recognize that tremendous improvements have been made
to our health-care system as a result of the enactment of the
Affordable Care Act in 2010. In fact, just this month, the U.S. Census
Bureau released a report that showed the U.S. uninsured rate fell to a
historic low of 8.8 percent in 2016. Since enactment of the ACA, we
have seen significant decreases in our national uninsured rate,
especially among vulnerable populations. We should be celebrating this
accomplishment and seeking ways to extend health-care coverage to those
who still lack it--not pursuing legislation that would drive up the
number of uninsured.
The GCHJ proposal, if enacted, would end the Medicaid expansion and its
financing and fundamentally alter the Medicaid program through
significant changes to that programs financing. In addition, the
proposal seeks to eliminate the tax subsidies currently available for
low to moderate income individuals purchasing their coverage on the
individual market. The bill attempts to replace these two coverage
opportunities through the establishment of an overly complex
methodology that would redistribute current federal financial support
through a state-by-state block grant system.
We are troubled by the fact that the GCHJ proposal appears to punish,
financially, those states that have taken the most meaningful steps to
expand coverage over the past few years and rewards those that chose to
forgo federal dollars that would have assisted their citizens in
securing health-care coverage. Our goal as a country should be to
increase coverage and provide continuing support to those who are doing
this well and additional support to those that need it. We should not
punish states for extending health-care coverage to individuals and
families.
We also are deeply concerned about the impact the proposal would have
on individuals with pre-existing conditions. The proposed legislation,
while retaining guaranteed issue provisions in current law, fails to
maintain other protections that protect patients with pre-existing
conditions. Yes, the proposal preserves access to health-care coverage
for everyone, but it exposes individuals with pre-existing conditions
to discriminatory pricing based on their health condition. In fact, the
proposal explicitly allows insurers to charge individuals with pre-
existing health conditions more, solely based on their health status.
Furthermore, the proposal, establishes a waiver process, which
currently lacks definition or criteria; that would allow states to no
longer comply with requirements that insurance products sold cover a
minimal set of benefits. Since the prohibitions on annual and lifetime
caps are tied to the essential health benefits under current law, the
proposal would allow insurance companies to once again impose annual
and lifetime caps on individuals and families.
The AAFP is increasingly concerned with the escalation in deductibles
that has occurred in the employer-sponsored, small group, and
individual insurance markets. Higher deductibles create a financial
disconnect between individuals, their primary care physician, and the
broader health-care system. The ACA has been successful in reducing the
number of uninsured individuals and families through expanded access to
health-care coverage, but the law has fallen short in reducing costs
and most specifically the out-of-pocket cost for individuals. In fact,
for some Americans, the law has provided increased access to health-
care coverage but has done so by increasing out-of-pocket cost through
higher deductibles.
In an effort to maximize the proven benefits of health-care coverage
and a continuous relationship with a primary care physician, the AAFP
proposes the establishment of a standard primary care benefit for
individuals and families with any high-deductible health plans (HDHP).
Our proposal would establish a standard primary care benefit for all
individuals with a high-deductible health plan. Individuals with a
HDHP, as defined by the Internal Revenue Service (IRS)*,
would have access to their primary care physician, or their primary
care team, without the cost-sharing requirements (deductibles and co-
pays) stipulated by their policy.
The AAFP agrees that innovation in care delivery are essential to
reducing costs. The AAFP has been a national leader in efforts to
better align our delivery and payment systems to produce higher-quality
care at lower cost. The GCHJ proposal points to one innovation we see
as a high-impact innovation in primary care. The proposal would support
the expansion of a delivery model commonly known as ``direct primary
care (DPC).'' The AAFP strongly supports DPC, but we do not see this
delivery model as an alternative to comprehensive health-care coverage.
There are bipartisan solutions, such as those mentioned above, to
challenges we face and the AAFP is standing ready to partner with you
and your colleagues to identify, develop, and implement those
solutions. On July 27, 2017, the AAFP sent a letter to Senate Leaders
outlining a set of bipartisan policies that we believe would be
appropriate steps towards improving our health-care system.
Health care is an immensely personal issue. Each of us, at some point
in our lives, will interact with the health-care system either as a
result of our own health issue(s) or the health issues of a family
member or loved one. Our individual views and opinions regarding our
health-care system are shaped by our experiences and observations, but
we all agree that health care and health-care coverage should be
accessible and affordable for every person and family.
Changes to current law must be patient-centered, be focused on
enhancing and improving our health-care system for all Americans, and
acknowledge the important role of family physicians and primary care in
our health-care system. Family physicians are on the frontline each day
providing care to millions of men, women, and children in communities
large and small, rural and urban, wealthy and poor across the country.
Today, one in five physician office visits takes place with a family
physician.
They are not only physicians, they also are patient advocates. They are
the physicians that individuals and their families turn to when they
are sick and when they are in need of guidance on life's most
complicated and challenging decisions. They are, without question, the
foundation of our health-care system.
Our members witness each day the importance of individuals and families
having health insurance coverage. They see the value of those patient-
centered protections that ensure each individual is able to obtain
health-care coverage regardless of their gender, health history, or
socioeconomic status. Our health-care system is not perfect and there
clearly are areas of our insurance and health-care system that require
additional reforms. The AAFP is committed to engaging in a dialogue and
process that identifies policies that strengthen our health-care system
and make health care more affordable for individuals and families at
all income levels.
The AAFP's policies and advocacy on these issues are guided by a
standard that has been proven the world over--the two primary factors
that are most indicative of better health and more efficient spending
on health care are continuous health-care coverage and having a usual
source of care, normally through a primary care physician.
Unfortunately, the GCHJ proposal is not consistent with this standard.
______
American Cancer Society Cancer Action Network (ACS CAN)
555 11th Street, NW, Suite 300
Washington, DC 20004
(t) 202-585-3241
(f) 202-661-5750
www.acscan.org
Washington, DC, September 25, 2017--Changes to the nation's health-care
system as proposed in the pending Graham-Cassidy health legislation
could leave millions of cancer patients and survivors without access to
adequate, affordable health insurance coverage, according to Dick
Woodruff, senior vice president of federal advocacy for the American
Cancer Society Cancer Action Network (ACS CAN).
During a Senate Finance Committee hearing, Woodruff told committee
members the bill essentially rolls back the patient protections
implemented under current law, including those for people with pre-
existing conditions. While plans would still be prohibited from denying
someone coverage based on their health history, in states that applied
for waivers, insurers could instead be free to charge people more for
their coverage based on their health status.
``For an individual in active cancer treatment or a cancer survivor,
the health plan could have no limit on the amount of the monthly
premium,'' said Woodruff. ``Products could be unaffordable for
individuals who required--or were anticipated to require--high cost
treatments.''
States could also apply to change what services plans are required to
cover, putting current guaranteed essential health benefits (EHB),
including coverage for hospitalization, physician services, specialty
cancer care and prescription drugs at risk.
``Insurance should cover the major health needs of cancer patients and
survivors,'' said Woodruff. ``Eliminating EHB requirements would
encourage insurers to streamline `basic' policies that do not include
explicitly defined comprehensive benefits, thus putting cancer patients
and survivors at risk of inadequate treatment, and could jeopardize
access to necessary preventive care, treatment and follow-up care.''
Woodruff added that because current law ties a prohibition on lifetime
or annual benefit limits to the EHB requirements, the Graham-Cassidy
proposal could once again bring back coverage caps, increasing the
chances that a cancer diagnosis or other serious condition could leave
patients financially devastated.
The bill would also make coverage much less affordable for many by
ending guaranteed premium subsidies and cost-sharing payments that help
low and moderate income Americans afford private coverage, and by
slashing Medicaid funding.
Medicaid serves as a vital safety-net and provides coverage to more
than 2.3 million Americans with a history of cancer, including one-
third of all pediatric cancer patients at the point of diagnosis.
``For low-income Americans, the changes proposed by Graham-Cassidy
could be the difference between an early diagnosis when outcomes are
better and costs are less or a late-stage diagnosis where costs are
higher and survival less likely,'' said Woodruff.
Woodruff urged senators to reject the Graham-Cassidy legislation and
instead resume bipartisan work to improve the health-care law that was
being done by Senators Lamar Alexander and Patty Murray.
``ACS CAN stands ready to work with the Committee and all Members of
Congress to develop and implement policies that will improve the
health-care system for the millions of individuals who are in active
cancer treatment and cancer survivors,'' said Woodruff.
To read the full written testimony: http://bit.ly/2fpEMNF.
______
American Civil Liberties Union (ACLU)
915 15th St., NW
Washington, DC 20005
On behalf of the American Civil Liberties Union (ACLU) and our more
than two million members and supporters, we submit this statement for
the record of the Senate Finance Committee's September 25, 2017 hearing
on the Graham-Cassidy-Heller-Johnson proposal (hereinafter ``Graham-
Cassidy''). We write in opposition to this legislation, which repeals
key provisions of the Affordable Care Act (ACA), harms people with
disabilities and women by cutting and capping Medicaid, denies patients
access to Planned Parenthood, and restricts abortion coverage. Though
the Congressional Budget Office has not had the opportunity to provide
a full analysis of the bill, there is no doubt that it would deprive
millions of people of the health-care coverage they need and without
which they cannot fully participate in the life of our nation.
Graham-Cassidy, like the various Senate health care repeal proposals
considered this summer, would decimate the Medicaid program. It would
both replace the Medicaid expansion with temporary and inadequate block
grants, and fundamentally restructure the over 50-year-old Medicaid
program by limiting federal financing through a per capita cap and
cutting billions from the program.
Medicaid cuts directly implicate basic freedoms for the disability
community. Medicaid is the vehicle that allows people to stay out of a
nursing home or other institution and to be able to live at home, with
family, in the community. Consider Curtis Wolff; who spoke at an ACLU
congressional briefing on the Medicaid program this June. In August
2012, Curtis was paralyzed due to a bite from a mosquito carrying the
West Nile Virus.\1\ Despite being a successful small business owner
with excellent private insurance, Curtis had to turn to Medicaid in
order to access home and community based services, in-home care that
enables people with disabilities to live their lives on their own terms
and get access to the support necessary to stay in the community.
---------------------------------------------------------------------------
\1\ Curtis Wolff, Opinion, ``I was paralyzed by a mosquito bite.
The GOP health care plan would be devastating for me,'' Denver Post,
June 29, 2017, available at https://www.denverpost.com/2017/06/29/i-
was-paralyzed-by-a-mosquito-bite-the-gop-health-care-plan-would-be-
devastating-for-me/.
We might wonder about what would have happened to Curtis in a nursing
home or similar institutional facility but Elizabeth Grigsby can speak
directly to that.\2\ She was born with cerebral palsy. Her disability
limits her control of her limbs, and slows her speech. As a young
woman, she was put in a Board and Care home run much like a nursing
home. She told us that ``someone else decided when I would get up in
the morning; someone else decided when and what I would eat for
breakfast; someone else decided who I would see and what I would do
that day. It was like being in prison--but I hadn't committed a
crime.''
---------------------------------------------------------------------------
\2\ Vania Leveille and Susan Mizner, ``Don't Underestimate the
Catastrophic Impact That the Trump Administration's Policies Will Have
on People With Disabilities,'' ACLU, January 23, 2017, available at
https://www.aclu.org/blog/disability-rights/integration-and-autonomy-
people-disabilities/dont-underestimate-catastrophic.
Like Curtis, Elizabeth was able to regain her freedom through in-home
service and support aids funded primarily by Medicaid. She now lives in
her own apartment, holds down a part-time job, and volunteers her time
helping medical professionals better understand how to work with people
with disabilities. And she can choose when, what, and with whom she
---------------------------------------------------------------------------
will eat breakfast.
Institutionalization severely limits the opportunities for people with
disabilities to make basic decisions about their own lives or to
interact with the broader community. Institutionalization is
segregation, locking Americans with disabilities away from the most
basic of freedoms. Over the last several decades, people with
disabilities have fought for--and increasingly won--greater access to
care and supports in the community. This is thanks to Medicaid.
Medicaid not only provides adults with mobility impairments with
support for daily activities, it also provides job coaching to adults
with intellectual and developmental disabilities so that they can enter
the workforce, and pays for in-home care for seniors to stay safely in
their homes.
To the disability community, there is no question that Medicaid needs
more funding, not less. Even with all this progress, hundreds of
thousands of people with disabilities are on waiting lists to receive
home and community services. There is not enough money to serve
everyone.
Slashing resources, through a per capita cap, will only exacerbate this
problem Researchers at the University of California, San Francisco
recently analyzed the impact per capita caps would likely have on the
disability community.\3\ This analysis found that, had such a system
been imposed in the last decade of Medicaid spending, funding for home
and community based services for seniors and people with physical
disabilities would have, on average, been cut by 30 percent, while
people with developmental disabilities would have seen a cut of as much
as 14 percent.
---------------------------------------------------------------------------
\3\ H. Stephen Kaye, Ph.D., ``The Potential Impact of the Better
Care Reconciliation Act on Home and Community-Based Services Spending
1'' (2017), http://clpc.ucsf.edu/sites/clpc.ucsf.edu/files/reports/
Impact%20of%20BCRA%20on%20HCBS%20spending%20updated%
207-14-17_0.pdf.
In short, Medicaid home and community based services funding has been
and continues to be the vehicle that advances the liberty of people
with disabilities. Without the current Medicaid program, countless
people with disabilities now living life on their own terms would be
forced into the regimentation and isolation of institutional life. This
result is unacceptable and should be rejected by every member of the
---------------------------------------------------------------------------
United States Senate.
Women, too, would be disproportionately impacted by per capita caps and
cuts to the program because they make up the majority of those enrolled
in Medicaid. Nearly 40 million women rely on Medicaid for care,
including 20 percent of women of reproductive age.\4\ For these women,
Medicaid coverage is essential to their ability to decide when,
whether, and how to start families. It covers 75 percent of publicly
funded family planning services and approximately half of all births in
the U.S.\5\ Graham-Cassidy's cuts to Medicaid would especially harm
women of color, who are enrolled in Medicaid at higher rates.
---------------------------------------------------------------------------
\4\ Adam Sonfield, ``Why Protecting Medicaid Means Protecting
Sexual and Reproductive Health,'' Guttmacher Policy Review 20 (2017),
https://www.guttmacher.org/sites/default/files/article_files/
gpr2003917.pdf.
\5\ Hanna Katch, et al., ``Medicaid Works for Women--But Proposed
Cuts Would Have Harsh, Disproportionate Impact,'' Center on Budget and
Policy Priorities, May 11, 2017, https://www.cbpp.org/sites/default/
files/atoms/files/5-11-17health.pdf.
Graham-Cassidy would hurt women's access to reproductive health care in
a variety of other ways. It would prevent patients enrolled in Medicaid
from seeking care at Planned Parenthood, which more than 2 million
people rely on annually for preventive care including cancer
screenings, birth control and testing and treatment for sexually
transmitted infections. This bill would force some Planned Parenthood
health centers to close their doors, leaving a void that could not be
filled by community health centers or other providers.\6\ In addition,
the bill would expand already harmful abortion coverage restrictions.
It would ban the use of tax credits for insurance policies that cover
abortion beyond cases of rape, incest, or life endangerment,
effectively eliminating coverage from the private insurance market
altogether, and restrict women's use of health savings accounts to
access abortion care.
---------------------------------------------------------------------------
\6\ Kinsey Hasstedt, ``Federally Qualified Health Centers: Vital
Sources of Care, No Substitute for the Family Planning Safety Net,''
Guttmacher Institute, May 17, 2017, https://www.
guttmacher.org/gpr/2017/05/federally-qualified-health-centers-vital-
sources-care-no-substitute-family-planning.
Finally, the bill allows states to waive key patient protections,
including the requirement that insurance cover maternity care, newborn
care, mental health and substance use treatment, prescription drugs,
and other Essential Heath Benefits. Maternity coverage was often
excluded from individual plans prior to the ACA, and may be again if
this bill becomes law. The bill also allows states to waive the ACA's
prohibition against charging higher premiums based on health status.
Before the ACA, insurers could discriminate against a person with a
disability or chronic condition, or a woman who was pregnant or had a
cesarean section, breast cancer, or who sought care to treat injuries
associated with domestic violence or other forms of gender-based
violence. Under Graham-Cassidy, insurance companies in some states
could charge significantly more for an insurance policy if an
individual has such a pre-existing condition, driving the cost of
coverage out of reach. Eliminating these protections will doubtless
have a negative and disproportionate impact on people with
disabilities, women, and other vulnerable populations who, prior to the
---------------------------------------------------------------------------
ACA, had difficulty obtaining insurance and care.
We strongly urge you to oppose and abandon this harmful and ill-
conceived legislation. Should you have any questions, please contact
Georgeanne Usova at (202) 675-2338 or gusova@acluorg, or Vania Leveille
at (202) 715-0806 or vleveille@acluorg.
______
American College of Emergency Physicians (ACEP)
2121 K St., NW, Suite 325
Washington, DC 20037
The American College of Emergency Physicians (ACEP) and our 37,000
members write to share our deep concerns with the recently released
proposal from Senators Cassidy, Graham, Heller, and Johnson to repeal
and replace the Affordable Care Act. We urge you not to bring this
amendment to the Senate floor for consideration, as its passage would
have devastating impacts on millions of Americans.
ACEP cannot support any legislation that does not include emergency
medical care as a covered benefit in health insurance. The Affordable
Care Act included emergency services as an essential health benefit,
and any replacement legislation must do the same. Yet the Cassidy-
Graham-Heller-Johnson Amendment to H.R. 1628, the American Health Care
Act, allows states to easily forego requiring insurers to adhere to
important consumer protections, including the requirement to cover the
10 essential health benefits, and protections for those with pre-
existing conditions.
We are very alarmed by reports that the Senate might proceed to a vote
on this proposal without a full score by the Congressional Budget
Office (CBO) on both coverage and financial impacts of the Cassidy-
Graham-Heller-Johnson amendment. It is clear that the proposal would
result in tens of millions of Americans losing health insurance
coverage through its drastic cuts to the Medicaid program,
destabilization of health insurance markets, and decreased access to
affordable coverage and care. The proposal directly challenges many of
ACEP's health care reform principles that we shared with you at the
start of the 115th Congress' health care reform debate, and would
result in devastating consequences for emergency medicine patients.
Americans overwhelmingly (95 percent) say health insurance companies
should cover emergency medical care \1\ and emergency physicians agree
with them. Patients can't choose when and where they will need
emergency care, and they shouldn't be punished financially for having
emergencies.
---------------------------------------------------------------------------
\1\ Morning Consult poll, February 9-10, 2017 (http://
newsroom.acep.org/2017-03-16-Public-Overwhelmingly-Wants-Insurance-
Companies-To-Cover-Emergency-Care-and-To-Be-Transparent).
We urge you to halt consideration of the Cassidy-Graham-Heller-Johnson
amendment, and instead work together in a bipartisan, bicameral, multi-
stakeholder effort to cultivate a health-care system that expands
access for patients, protects consumers, encourages innovation, and
---------------------------------------------------------------------------
ensures the continued availability of health-care providers.
______
American College of Physicians (ACP)
25 Massachusetts Avenue, NW, Suite 700
Washington, DC 20001-7401
202-261-4500
800-338-2746
https://www.acponline.org/
As the Senate Finance Committee considers the merits of the Graham-
Cassidy-
Heller-Johnson (GCHJ) proposal to repeal and replace the Affordable
Care Act (ACA), the American College of Physicians (ACP) would like to
take this opportunity to provide our view that the Senate should not
move forward with this bill. We outlined our opposition to the initial
version of this legislation in our September 13th letter that detailed
many of the reasons why it would undermine or eliminate health-care
coverage, benefits, and consumer protections for millions of people.
Based on the most recent version of this legislation that was released
on September 25th, we reaffirm our strongest possible opposition to the
new draft of the bill as it would make it even more harmful to our
patients by creating new and perhaps insurmountable coverage barriers
for Medicaid enrollees, and patients with pre-existing conditions and
for the many millions of Americans who will be priced out of coverage,
or will pay more for less coverage.
We are dismayed that the revised bill is an even more blatant violation
of regular order because it was released just hours ago, with a vote
possible in the Senate by Friday. As a result, the Congressional Budget
Office (CBO) will have no time to do a complete cost and coverage
estimate of GCHJ's impact by the time a vote is taken, there will be no
committee mark ups, no time for other independent analyses and
stakeholder input, and just a single, cursory hearing today that does
not even allow time for the public to offer testimony that reflects a
thorough review of the latest revised bill.
ACP urges the Finance Committee to move forward with the development of
bipartisan legislation to stabilize the health insurance marketplace,
create competition among insurers, and lower the cost of health care
for all Americans. We believe that the bipartisan hearings that
occurred earlier this month in the Senate Finance Committee on health-
care issues impacting cost and coverage and in the Senate HELP
Committee on ways to stabilize and lower premiums in the individual
insurance market offer a good starting point for the consideration of
such health reform proposals.
ACP is the largest medical specialty organization and the second
largest physician group in the United States, representing 152,000
internal medicine physicians (internists), related subspecialists, and
medical students. Internal medicine physicians are specialists who
apply scientific knowledge and clinical expertise to the diagnosis,
treatment, and compassionate care of adults across the spectrum from
health to complex illness.
ACP has developed criteria, 10 key questions that should be asked to
ensure that any legislation that would alter the coverage and consumer
protections under current law ``first, do no harm'' to patients and
ultimately result in better coverage and access to care for essential
medical services. We remain concerned the GCHJ legislation falls well
short of meeting the criteria that we have established to ensure that
the health of patients is improved rather than harmed by changes to
current law.
Medicaid
The GCHJ legislation would eliminate or weaken coverage for individuals
insured through Medicaid by eliminating the enhanced federal match
provided under the ACA for states that opt to expand the Medicaid
program starting on January 1, 2020. It would allow states to
redetermine Medicaid eligibility for individual's eligible every 6
months or more frequently for individuals eligible for Medicaid through
the ACA expansion or the state option for coverage for individuals with
income that exceeds 133 percent of the federal poverty level. This
change would result in a substantial number of citizens who reside in
states that expanded their Medicaid population that would lose coverage
under this legislation, with no assurance that they would be covered
under a state plan or in the marketplace. It would put at risk the
gains that we have made under the ACA in ensuring that low income
individuals would have coverage and a regular source of care to
maintain their well-being or treat illness when they are sick.
It would also significantly decrease federal funding for the Medicaid
program by converting the current federal financing formula to a per
capita cap model. The proposed per capita cap on federal funding would
be devastating to coverage and access to care for many of the 72
million people currently enrolled in Medicaid. Because most states are
required by law to balance their budgets, a reduction in and/or a cap
on federal matching funds will necessarily require them to greatly
reduce benefits and eligibility and/or impose higher cost-sharing for
Medicaid enrollees, most of whom cannot afford to pay more out of
pocket--or alternatively and concurrently, reduce payments to
physicians and hospitals (including rural hospitals that may be forced
to close), enact harmful cuts to other state programs or raise taxes.
The GCHJ proposal would also allow states the option to participate in
a Medicaid Flexibility block grant program beginning in Fiscal Year
2020. Under the Medicaid Flexibility Program, states would receive
block grant funding instead of per-capita cap funding for non-elderly,
non disabled, and non-expansion adults. We remain opposed to this block
grant funding structure as we believe it would be devastating to
coverage and access to care especially under this legislation as
overall federal funding for Medicaid would be reduced from current law.
Under block grants, because states do not get any additional payment
per enrollee, strong incentives would be created for states to cut back
on eligibility, resulting in millions of vulnerable patients
potentially losing coverage. Block grants will not allow for increases
in the federal contribution should states encounter new costs, such as
devastating hurricanes, flooding or tornadoes that may injure their
residents or destroy health-care facilities. Under either block grants
or per capita spending limits, states would be forced to cut off
enrollment, slash benefits, or curb provider reimbursement rates.
The GCHJ legislation would also permit states, effective October 1,
2017, to require non-disabled, non-elderly, non-pregnant individuals to
satisfy a work requirement as a condition for the receipt of Medicaid
medical assistance. We oppose work requirements because Medicaid is not
a cash assistance or job training program; it is a health insurance
program and eligibility should not be contingent on whether or not an
individual is employed or looking for work. While an estimated 80
percent of Medicaid enrollees are working, or are in working families,
there are some who are unable to be employed, because they have
behavioral and mental health conditions, suffer from substance use
disorders, are caregivers for family members, do not have the skills
required to fill available positions, or there simply are no suitable
jobs available to them. Skills--or interview-training initiatives, if
implemented for the Medicaid population--should be voluntary, not
mandatory. Our Ethics, Professionalism and Human Rights Committee has
stated that it is contrary to the medical profession's commitment to
patient advocacy to accept punitive measures, such as work
requirements, that would deny access to coverage for people who need
it.
The bill requires all states to establish their own system for
financing health care by 2020, or risk losing all federal block grant
funding. This would be highly disruptive and nearly impossible task for
most states to accomplish in that time frame. It would also authorize
massive redistribution of funding from states that expanded Medicaid
coverage to the most vulnerable to those that did not, resulting in
billions of dollars in cuts to Medicaid expansion states. In addition,
all federal Medicaid funding to the states will sunset in 2027, when
all states would lose federal block grant funding unless funding is
reauthorized.
Medicaid is an essential part of the health care safety net. Studies
show that reductions in Medicaid eligibility and benefits will result
in many patients having to forgo needed care, or seek care in costly
emergency settings and potentially have more serious and advanced
illnesses resulting in poorer outcomes and even preventable deaths. As
an organization representing physicians, ACP cannot support any
proposals that would put the health of the patients our members treat
at risk. We believe though that improvements can and should be made in
Medicaid, including more options for state innovation, without putting
the health of millions of patients at risk.
Premium Tax Credits
This proposal would repeal the ACA premium tax credits as of January 1,
2020 and allocate some of the funds that were used for that purpose to
a new Market Based Health Care Grant Program. States would be able to
use payments allocated from the program for one or more of the
following activities:
To establish or maintain a program or mechanism to help high-
risk individuals purchase health benefits coverage, including by
reducing premiums for such individuals, who have or are projected to
have high health care utilization (as measured by cost) and who do not
have access to employer-sponsored insurance;
To establish or maintain a program to enter into arrangements
with health insurance issuers to assist in the purchase of health
benefits coverage by stabilizing premiums and promoting market
participation and plan choice in the individual market;
To provide payments for health care providers for the provision
of services specified by the CMS Administrator;
To provide health insurance coverage by funding assistance to
reduce out-of-pocket costs (such as copayments, coinsurance, and
deductibles) for individuals with individual health insurance coverage.
We remain concerned that this formula provides less funding than
currently in place for individuals to purchase health insurance in the
individual market and that states could use these funds for a broad
range of health-care purposes, not just coverage, with essentially no
guardrails or standards to ensure affordable meaningful coverage.
The estimates from the bill's sponsors and/or administration showing
that many states will receive more federal dollars under the GCHJ
Market Based Health Care Grant Program does not appear to take into
consideration the impact of the Medicaid per-capita limits and
reduction in the federal contribution to Medicaid. Even in the select
states that the sponsors (questionably) assert will experience short-
term gains in funding, all states are expected to experience reductions
when the impact of Medicaid caps and cuts, and the expiration of
funding in 2027, are taken into account. Any temporary increase in
funding to a few states does not make up for the damage that will be
done to their residents, and those of other states, resulting from
eliminating essential patient protections and capping and cutting
Medicaid. GCHJ would plunge the country back to the pre-ACA days when
people with pre-existing ``declinable'' medical conditions in most
states were priced out of the market and the insurance products
available in the individual market did not cover medically necessary
services.
Rather than grant states large sums of funding to use on the options
listed in this legislation that offer no assurance of increased access
to coverage, we wish to work with you to enact meaningful reforms to
strengthen the individual market and build on the gains in health-care
coverage ensured by the ACA. ACP has offered a forward looking document
that provides our prescription for meaningful reforms to accomplish
these goals.
Elimination of Essential Health Benefits and Other Consumer Protections
We are alarmed that the most recent changes to the GCHJ legislation
would do even more harm to individuals with pre-existing conditions by
making it even easier for states to opt out of essential health
benefits (EHBs) and could also allow annual and lifetime limits on
patient coverage, resulting in bare-bones coverage. States will only
have to submit to the Department of Health and Human Services a broad,
undefined statement that they ``shall'' provide access to affordable
coverage with insufficient or non-existent guardrails of what that is
or requirements to ensure that such coverage is truly affordable.
States could offer plans with lower or no ``actuarial equivalent''
standards, meaning higher deductibles and out-of-pocket costs for
patients.
We believe that Congress should consider additional policies to
encourage state innovation and bring more choice and competition into
insurance markets without rolling back current coverage, benefits and
other consumer protections guaranteed by the ACA and other federal laws
and regulations. Provided that coverage and benefits available in a
particular state would be no less than under current law, Congress
should encourage the use of existing section 1332 waiver authority to
allow states to adopt their own innovative programs to ensure coverage
and access. Section 1332 waivers offer states the opportunity to test
innovative ways to expand insurance coverage while ensuring that
patients have access to comprehensive insurance options. However, ACP
believes that Congress should not weaken or eliminate the current-law
guardrails that ensure patients have access to comprehensive essential
health benefits and are protected from excessive co-payments and
deductibles. The waiving of essential benefits would undermine the
assurance that insurance policies would cover essential health-care
services such as physician and hospital benefits, maternity care and
contraception, mental health and substance use disorder treatments,
preventive services, and prescription drugs.
Unfortunately, if existing requirements were removed (e.g., that
waivers provide comprehensive, affordable coverage that covers a
comparable number of people as would be covered under current law), a
backdoor would emerge for insurers to offer less generous coverage to
fewer people and to make coverage unaffordable for patients with
preexisting conditions. As long as a state's waiver program meets the
ACA's standard of comprehensiveness at the same cost and level of
enrollment, it can test a more market-based approach, or make other,
more targeted revisions to continue existing state initiatives.
Elimination of the Individual and Employer Mandates
The GCHJ legislation eliminates the mandate that requires individuals
to pay a penalty if they do not acquire health insurance or employers
with 50 or more full time workers to pay a fine if they do not provide
health insurance for their employees. We are concerned that the
elimination of this mandate would allow individuals to wait until they
are ill to purchase insurance and that insurers would need to increase
premiums to compensate for the resulting sicker risk pool and the
destabilization of the insurance market. Maintaining effective
adherence to the mandate helps balance the market's risk pool, attract
healthier employees, and avoid dramatic premium rate increases. In
addition, Congress should not enact any legislation to weaken or repeal
the individual insurance requirement absent an alternative that will be
equally or more effective.
Conclusion
In July of this year, the Senate failed to garner the necessary votes
in the process of moving forward with legislation to repeal and replace
the Affordable Care Act in a budget reconciliation bill. Rather than
continue with an effort to repeal and replace the Affordable Care Act,
we urge you to set aside this legislation and instead, focus on
bipartisan efforts to improve coverage and lower costs based on the
hearings that were held in the Senate Finance and HELP Committee
earlier this month. We also urge that any legislation to amend current
law should be developed through regular order, with hearings, debate,
and committee mark-ups, and with sufficient time for comprehensive
independent analysis by the Congressional Budget Office (CBO),
independent experts, and the clinicians and patients directly affected
by the proposed changes. We stand ready to work with you should our
expertise be of help.
______
American Diabetes Association
2451 Crystal Drive, Suite 900
Arlington, VA 22202
1-800-DIABETES
http://diabetes.org/
American Diabetes Association Urges Senators to Oppose Graham-Cassidy
Repeal Bill and Continue Working on Bipartisan Health Care Legislation
Proposal would be devastating for the more than 30 million Americans
living with diabetes.
The American Diabetes Association is extremely concerned with the
Graham-
Cassidy health care bill and the impact it will have on people with
diabetes. Individuals with diabetes need ongoing access to health care
to effectively manage their disease and to prevent dangerous and costly
complications. Access to affordable, adequate health coverage is
critical to people with diabetes. The proposed legislation does not
guarantee this access and would instead increase costs and jeopardize
care for those with pre-existing conditions such as diabetes. The
Association urges Senators to vote against this misguided and harmful
legislation should it be brought to a vote in the Senate.
The Association is deeply troubled by many aspects of the Graham-
Cassidy bill. It allows states to opt out of key insurance protections
for patients, including the ban on charging people with preexisting
conditions higher premiums and requirements that ensure adequacy of
coverage. This would put people with diabetes at risk of being unable
to get the care necessary to manage their disease. In addition, the
bill is estimated to slash more than $4 trillion in vital health-care
funding to states by 2036, and lumps all funding for health programs
designed or administered by states into a single block grant. States
will have a limited amount of funds available for multiple critical
health-care programs, such as offering low- and moderate-income people
coverage or financial assistance and covering adults under Medicaid,
and will be forced to make difficult trade-offs in determining how the
funds are used. Even worse, the funding is cut off completely after
2026.
The bill also makes drastic changes to the financing structure of the
Medicaid program. In addition to repealing funding for the Medicaid
expansion program, the bill converts the traditional Medicaid program
to a fixed per-capita cap, severely limiting the funding provided to
states. It is estimated that this bill would cut federal Medicaid
funding to states by $489 billion by 2027. These cuts would have a
devastating impact on low-income Americans, who are disproportionately
affected by diabetes. In states that expanded their Medicaid programs,
more individuals are being screened for diabetes than non-expansion
states. Cuts to Medicaid would leave the most vulnerable individuals
with, or at risk for, diabetes without the health coverage they need to
be diagnosed and treated for the disease as early as possible.
The Association is also alarmed that the Senate would vote on this
legislation without understanding its full impact on insurance coverage
for millions of Americans. The Congressional Budget Office (CBO), which
provides nonpartisan estimates on the impact of proposed legislation,
recently announced that they would take several weeks to provide an
estimate on the number of Americans who might lose their coverage under
this bill. We ask the Senate leadership to not hold a vote on this bill
until they have a full understanding of the impact it will have on all
Americans. The well-being of millions of Americans with diabetes is at
risk.
The Association opposes the Graham-Cassidy legislation because it falls
short of the minimum standards for replacing the important safeguards
and coverage provided by the Affordable Care Act (ACA), which the
Association has outlined. We urge the Senate to reject this bill and
continue negotiations on a bipartisan health care bill that will
protect access to affordable and adequate health coverage for people
with diabetes.
If you have any questions, please contact Rob Goldsmith, Director,
Federal Government Affairs at [email protected] or 703-253-4837.
______
American Heart Association
1150 Connecticut Ave, NW
Washington, DC 20036
202-785-7900
Statement of Nancy Brown, Chief Executive Officer
The American Heart Association is the nation's oldest and largest
voluntary organization dedicated to building healthier lives free from
heart disease and stroke--two of the leading causes of death in the
United States. Our non-profit, non-partisan organization works with
more than 30 million volunteers and supporters across the country and
in your state. Today, one out of three Americans suffer from one or
more forms of cardiovascular disease (CVD).
We welcome the opportunity to share our concerns about the Graham-
Cassidy-
Heller-Johnson health-care proposal on behalf of our volunteers,
clinicians, supporters, and the millions of other constituents with, or
at risk of developing CVD. We believe this legislation would cause
millions to lose coverage, eliminate or weaken access to care for
people with preexisting health conditions, increase out-of-
pocket costs for individual market consumers, and allow insurers to
reduce or eliminate essential health benefits that are critical for
individuals with CVD and stroke. We believe this proposal will do
irreparable harm to the patients that we represent. We urge the
Committee to reject this plan and resume bipartisan discussions aimed
at strengthening--rather than weakening--access to the care Americans
need and deserve.
Why We Care
The connection between health insurance and health outcomes is clear
and well documented. For instance, Americans with CVD risk factors who
lack health insurance, or are underinsured, have higher mortality rates
and poorer blood pressure control than those who are insured; uninsured
stroke patients suffer from greater neurological impairments, longer
hospital stays and higher risk of death than similar patients covered
by health insurance; and uninsured and underinsured patients are more
likely to delay seeking medical care during an acute heart attack.
Lack of comprehensive coverage also impacts the financial stability of
those individuals. More than 60 percent of all bankruptcies in 2007
were a result of illness and medical bills, and more than a quarter of
these bankruptcies were the result of CVD. Nearly 80 percent of those
who filed for medical bankruptcy were insured. In a survey commissioned
by the American Heart Association, one in five (21 percent) of
respondents said they ``frequently'' put off care because of the costs
involved. Among those with heart disease, 51 percent said they
occasionally put off care because of costs, with 20 percent saying they
``frequently'' delay care. In addition, heart transplants and surgeries
for the approximately 40,000 babies born with heart defects each year
are clear examples where caps on coverage can be quickly reached.
Low-income populations are disproportionately affected by CVD--with
low-income adults reporting higher rates of heart disease,
hypertension, diabetes, and stroke. Americans with a history of CVD
make up 28 percent of the Medicaid population. Medicaid provides
critical access to prevention, treatment, disease management, and care
coordination services for low income people with CVD.
In addition, older Americans, like many of the patients we represent,
are more likely to have a preexisting health condition.
AHA's Health Care Reform Priorities
Our association, in collaboration with 20 other non-partisan patient
and provider organizations, developed a set of core principles that are
fundamental to ensuring Americans continue to have access to affordable
and adequate health care. In addition to preserving the coverage gains
we have achieved in recent years, we believe that three key elements--
affordability, accessibility and adequacy of health care coverage--must
be incorporated into any proposal to alter existing law. Our groups
agreed to evaluate any proposed changes based on these key
considerations.
It is important to note that this legislation is being rushed through
Congress to meet an arbitrary budget deadline, so a complete analysis
of this bill from the Congressional Budget Office (CBO) is not
available. Therefore, our evaluation of the impact on our patient
population is based largely on other independent sources. While these
sources may differ in some respect, they all demonstrate that this
legislation does not come close to meeting the principles patients
groups have endorsed and represent a major step backward in health-care
coverage for our nation.
Health Care Coverage
The AHA believes that any changes to existing law must not jeopardize
the health-care coverage Americans currently have through employers,
the private marketplace, Medicare or Medicaid. The Graham-Cassidy
legislation fails that test.
The coverage losses estimated by the CBO for the previous health-care
bills ranged from 22 million in the Senate-reported American Health
Care Act to 24 million in the House-passed Better Care Reconciliation
Act. The Commonwealth Fund has estimated that 32 million people could
lose coverage under the Graham-Cassidy proposal after 2026--and that
15-18 million people could become uninsured in the first full plan year
after enactment. An analysis by The Brookings Institution found that
the legislation would reduce the number of people with insurance
coverage by 15 million between 2018 and 2019; 21 million between 2020
and 2026 and 32 million in 2027 and later.
It's not surprising that these estimates are higher than the previous
bills because the legislation would effectively repeal the Affordable
Care Act's (ACA) major coverage expansions after 2026, and make
increasingly severe federal funding cuts to the rest of the Medicaid
program (outside of the expansion) under its per capita cap proposal.
But even without a CBO estimate of coverage losses the math is
straightforward. According to several sources, the proposal being
considered by the Finance Committee would reduce the federal commitment
to health care by as much as $215 billion through 2026 and more than $4
trillion over a 20-year period. Any ``flexibility'' given to the states
could not possibly replace cuts of this magnitude--a point made
strongly by the National Association of Medicaid Directors, who
expressed their concern that ``this legislation would undermine efforts
in many states and fail to deliver on our collective goal of an
improved health care system.'' In speaking about the block grant
structure proposed in the Graham-Cassidy legislation, Avalere Health
writes, ``funding cuts of this magnitude will force states to re-
evaluate their Medicaid programs, including the number of individuals
covered and the generosity of the provided benefits.'' This is
unacceptable.
The ACA brought about significant coverage gains across the U.S.
population and for CVD patients, specifically. A study released in 2016
by the American Heart Association revealed that more than 6 million
adults at risk of CVD and 1.3 million with heart disease, hypertension
or stroke gained health insurance between 2013 and 2014. The numbers
are likely much higher today. This coverage expansion brought about
both health and financial status improvements. In Oregon, full
implementation led to a 17 percent reduction in deaths from sudden
cardiac arrest for those aged 45-64. In Massachusetts, health-care
expansion led to a nearly 3 percent decline in all-cause mortality, a
nearly 7 percent reduction in the number of uninsured and a 3 percent
decline in all-cause mortality. Additionally, over the period since
ACA's passage, personal financial bankruptcies have dropped by 50
percent.
Medicaid expansion has been particularly beneficial for individuals
with or at risk of developing CVD. A 2016 study conducted by the George
Washington University found that adults who live in non-expansion
states are at higher risk of CVD, or are more likely to have
experienced acute CVD, while also having lower insurance coverage
rates. Patients in non-expansion states may also have greater
difficulties getting preventive, primary or acute care. It is harder
for the physicians treating these patients to collect insurance
payments for their services as well. This translates into significantly
worse health outcomes for patients and a lost opportunity to
incentivize cost-efficient care.
This legislation could largely reverse the coverage gains achieved
since the Affordable Care Act was enacted in 2010. These losses would
likely be more concentrated among people with pre-existing conditions
and serious health needs--the very people who need health insurance the
most. Our association finds these coverage losses and the impact it
would have on the lives and health of Americans with CVD unacceptable.
Access to Care and Preexisting Conditions
Our association believes that access to care must be maintained by
preserving patient protections currently in place, which include
prohibitions on preexisting condition exclusions, annual and lifetime
limits, insurance policy rescissions, gender pricing and excessive
premiums for older adults. The Graham-Cassidy legislation fails that
test.
Many of our patients were uninsurable prior to passage of the ACA, or
they were simply priced out of the insurance market. An analysis of
some of the largest for-profit health insurance companies in the
country revealed that between 2007 and 2009, one out of every seven
applicants was denied coverage based on a health condition. This
highlights the widespread discrimination that has impacted CVD patients
for decades.
In addition, preexisting conditions are clearly linked to age: 75
percent of those aged 45 to 54 and 84 percent of those ages 55 to 64
have one or more preexisting condition. Hypertension tops the list and
high cholesterol ranks fourth. This is of particular concern because
individuals with CVD tend to be older.
Although the sponsors of this legislation claim that these patients are
protected, several independent sources disagree. This legislation
allows states to waive both the ACA's prohibition against charging
higher premiums based on health status and the requirement that
insurers cover essential health benefits (or cover them adequately). In
addition, caps on lifetime limits are tied to the existence of
essential health benefits, so those too could be re-imposed. Unlike the
ACA's Section 1332, there are no coverage ``guardrails'' limiting the
waivers. Instead, states must describe in their waiver applications how
individuals with pre-existing conditions will have ``adequate'' and
``affordable'' coverage. There is no definition in the law of what
adequate and affordable coverage actually means.
Based on a detailed analysis for the CBO, 50 percent of the U.S.
population lives in states that are likely to enact waivers eliminating
consumer protections or reducing required benefits. Therefore,
protections that our patients have relied are no longer guaranteed. CBO
estimates of a similar model found that less healthy individuals, such
as those with preexisting conditions, would be unable to purchase
comprehensive coverage with premiums close to those under the current
law and might not be able to purchase coverage at all. For those who
can acquire coverage, their premiums will likely rise despite
additional funding.
The ACA offered coverage to CVD patients who had previously been
without, either because they were denied coverage in the individual
market due to their preexisting condition, or because of expensive
premiums that were out of their financial reach. For the first time,
they were offered a genuine pathway to real and meaningful health
insurance coverage. This legislation removes the guarantee of coverage
for individuals with preexisting health conditions, which is
unacceptable to the association and the individuals we represent.
Affordability
Affordable plans ensure that patients are able to access needed care in
a timely manner from an experienced provider without undue financial
burden. Affordable coverage includes reasonable premiums and cost
sharing (such as deductibles, copays and coinsurance) and limits out-
of-pocket expenses. Adequate financial assistance must be available for
low-income Americans and individuals with preexisting conditions. They
should not be subject to increased premium costs based on their disease
or health status. The Graham-Cassidy legislation fails that test.
Older and sicker people make up a significant portion of our patient
population. The bill eliminates two sources of financial assistance for
that population--premium tax credits and cost sharing reductions. This
assistance is critical to ensuring low- to moderate-income older adults
are able to afford the coverage they need. The bill also allows states
to charge older adults aged 50-64 significantly higher premiums on the
basis of their age than what states charge under the current law by
waiving federal protections that limit the practice known as age
rating. For example, under current law, a 60-year-old earning $25,000 a
year would pay an average of $1,608 per year in health insurance
premiums in 2020. Under the proposed legislation, however, he or she
could see their premiums increase by as much as $10,572 in 2020 at the
national level--amounting to a total $12,180--due to the elimination of
tax credits. In Alaska, for instance, a 60-year old earning $25,000
buying insurance in the Marketplace could see their premiums increase
as much as $26,986.
Cardiovascular disease is the costliest condition in America. An
unaffordable plan is no different than a coverage denial for our
patients. This legislation would reduce the affordability of plans on
the exchange, particularly for older people, and cuts in Medicaid could
terminate coverage to individuals based on each state's decision about
which individuals they choose to cover. This is a dramatic step
backward from the current law. It is unacceptable to us and our
patients.
Adequacy
In addition to maintaining access to insurance coverage, all plans
should be required to cover a full range of needed health benefits,
with a comprehensive and stable network of providers and plan features.
The provision in current law that requires all individual and small-
group plans, whether in or out of the marketplaces, to cover 10
categories of required services is critically important to individuals
with heart disease--particularly, rehabilitation and habilitation
services, as well as preventive health care. The Graham-Cassidy
legislation fails that test.
Previously, many plans in the individual and small-group markets lacked
coverage in one or more of the 10 essential benefit categories. For
people living with or at risk of CVD the benefit requirements in the
ACA protected insured individuals from overwhelming financial burden in
the event of a CVD-related illness. It also enabled them to receive
health-care services that help prevent a recurrence or disease
progression.
According to the CBO, about half of the population resides in states
that would make changes to essential health benefits given the chance.
People who rely on these services could face drastic increases in out-
of-pocket costs or forgo needed services, including maternity care,
mental health and substance abuse treatment, and rehabilitative and
habilitative services.
Preventive care is critically important for patients if we are going to
make notable progress towards controlling CVD, which is the deadliest
and costliest disease in our nation. Currently, the preventive
screenings required under current law apply to nearly all individual
and small-group plans, most large group plans and all Medicaid
expansion plans. Enrollees have access to a broad set of evidence-based
preventive services without cost-sharing requirements, and these
services include many that are relevant to preventing, identifying, and
managing CVD: blood pressure screening, diabetes (type 2) screening,
diet counseling, statin preventive medication for those with CVD risk,
and obesity screening and counseling. These are all core components to
preventing, diagnosing or treating CVD. Evidence demonstrates that when
preventive services come with out-of-pocket costs, utilization rates
fall, particularly for the working, low-income population. An
investment in preventive services prevents significant loss of work-
days and improves quality of life for millions of heart and stroke
patients. Once again, the continuation of these benefits would be left
up to the states, putting them in jeopardy for the millions of patients
who could benefit from them.
Conclusion
On behalf of the millions of individuals struggling with heart disease
and stroke, we urge the Committee to oppose this legislation that fails
every test of adequate and affordable health-care coverage. We press
the committee to instead consider bipartisan approaches to stabilizing
the insurance markets, like those considered by the Health Education
Labor and Pensions (HELP) Committee. The AHA stands ready to work with
Congress to draft meaningful legislation to improve access to
affordable, adequate health coverage for all.
______
American Hospital Association (AHA)
800 10th Street, NW
Two CityCenter, Suite 400
Washington, DC 20001-4956
Phone (202) 638-1100
https://www.aha.org/front
On behalf of our nearly 5,000 member hospitals, health systems and
other health-care organizations, as well as our clinician partners--
including more than 270,000 affiliated physicians, 2 million nurses and
other caregivers--and the 43,000 health-care leaders who belong to our
professional membership groups, the American Hospital Association (AHA)
appreciates the opportunity to submit for the record our comments on
the importance of maintaining coverage and access to care as the Senate
considers a proposal that would radically transform the health-care
system.
The AHA opposes the Graham-Cassidy-Heller-Johnson proposal. This
proposal cuts or repeals major health care coverage programs without
putting an adequate alternative in place, placing coverage for tens of
millions of Americans at risk. The exact impact of this proposal is
uncertain as the Congressional Budget Office (CBO) has been unable,
thus far, to fully analyze the proposal. However, an analysis conducted
by KNG Health Consulting for the AHA found that more than 20 million
individuals would lose coverage by 2026, and the proposal would result
in $275 billion less in federal funding to states. This is similar to
CBO projections for an earlier proposal, which found that 22 million
individuals or more would lose coverage, and hundreds of billions of
dollars would be cut from the health care system. Moreover, while some
states may receive additional federal funds under the proposal, our
analysis found that the rate of uninsured would increase in every
state. We urge the Senate to go back to the drawing board and work in a
bipartisan manner to address the challenges facing our nation's health-
care system.
Among the AHA's key concerns with the Graham-Cassidy-Heller-Johnson
proposal:
The Proposal Would Result in Millions Losing Health Coverage. The
proposal would repeal the Affordable Care Act's (ACA) individual and
employer mandate penalties, and it would slash funding for traditional
Medicaid by transitioning financing for the program to a per capita cap
model with trend factors that are generally below historic spending
growth, jeopardizing coverage for our most vulnerable. Finally, the
proposal would repeal Medicaid expansion, the Basic Health Program, and
the Health Insurance Marketplace subsidies--through which more than 20
million people receive coverage--and direct a portion of the funds for
those programs to establish a state grant program. The proposal would
provide approximately $200 billion less than the federal government
would spend under current law.\1\ The proposal, as updated on September
24, 2017, would also direct approximately $4.5 billion to several
states based on whether the state expanded Medicaid after December 31,
2015 \2\ or has an approved 1332 waiver that provides federal ``pass-
through'' funding to the state. Only a handful of states--Alaska,
Hawaii, Louisiana, Montana and Minnesota--would qualify for these
additional funds. There are few guidelines for states on how to use the
grant funds, including no requirement that states even use the money
for coverage. Finally, this program and the funding available through
it would end entirely at the conclusion of 2026, without any plan for
how to continue coverage for those who do benefit from the program.
---------------------------------------------------------------------------
\1\ KNG Health Consulting, LLC.
\2\ The draft legislative language provides that the additional
funds are for states that expanded after December 31, 2016, but the
summary document indicates that the provision applies to states that
expanded after December 31, 2015. We assume the date in the draft
legislative language is a drafting error as no states expanded after
December 31, 2016.
Transitioning Medicaid to a Per Capita Cap Financing Model Would
Reduce Program Funding to Unsustainable Levels Over Time. The
proposal's per capita spending limits would reduce federal Medicaid
funding to unsustainable levels over time. From 2020 to 2026, states
would receive billions less than under current law.\3\ Once even
stricter caps go into effect, the cuts would jump dramatically and grow
larger over time. While the proposal would provide just two states--
Alaska and Hawaii--with increased federal Medicaid funds through an
increase in their FMAP, for all other states, these cuts would force
state Medicaid programs to make tough choices about how to manage their
remaining Medicaid dollars and would result in additional coverage
losses.
---------------------------------------------------------------------------
\3\ Id.
Medicaid serves our most vulnerable populations, including
Americans with chronic conditions such as cancer, the elderly and
disabled individuals in need of long-term services and support; and the
program already pays providers significantly less than the cost of
providing care. The proposed restructuring of the Medicaid program and
the resulting deep financial cuts will have serious negative
---------------------------------------------------------------------------
consequences for communities across America.
The Proposal Incentivizes States to Cover Only a Sliver of Those
Currently Enrolled. The proposed grant program would ultimately provide
each state with a standard amount of money per ``low-income
individual,'' subject to some adjustments. The proposal defines a low-
income individual as someone with income between 45 and 133 percent of
poverty.\4\
---------------------------------------------------------------------------
\4\ Effectively 50 to 138 percent of poverty when accounting for a
5 percent income disregard.
States would be subject to a reduction in their allotment
depending on how many individuals within this income range do not have
comprehensive coverage. In addition, based on changes in the September
24, 2017 draft of the proposal, at least half of the grant funds must
be used to provide assistance to people with incomes between 45 and 295
percent of poverty. While we support incentivizing enrollment in
comprehensive coverage, we question why the proposal does not
incentivize states to cover individuals below 45 percent of poverty.
The proposal sponsors suggest that the selected income range
``represents the population currently on Medicaid expansion. This
population disproportionally struggles to access health insurance, and
is, therefore, a better population to use when assessing need and
determining state allotments.'' \5\ Presumably, the millions of
individuals below 45 percent of poverty, including those who lose
coverage due to the repeal of Medicaid expansion, similarly struggle to
access coverage.
---------------------------------------------------------------------------
\5\ Graham-Cassidy-Heller-Johnson: Frequently Asked Questions,
accessed on Sept. 21, 2017 at: https://www.cassidy.senate.govlimo/
media/doc/GCH%20FAQs%20Final.pdf.
The Proposal Would Erode Key Protections for Patients and Consumers.
Under the grant program, states could waive certain consumer
protections related to essential health benefits and some elements of
community rating, among other insurance market provisions. As a result,
insurers could sell inadequate coverage and charge individuals with
pre-existing conditions any amount in premiums. Changes to the proposal
introduced on September 24, 2017 fail to ensure that such individuals
---------------------------------------------------------------------------
would not be priced out of coverage.
The Proposal Does Not Provide States With Adequate Time to Implement
New Coverage Programs. The law would provide states with less than 2
years to wind down current coverage programs and develop alternatives.
We do not believe this provides states with adequate time to address
the myriad issues they will face, including: to what type of coverage
model the state would transition; who would be eligible for coverage;
how the state would handle disenrollment from current coverage
programs; whether the state would reform insurance market rules; and
the building of new coverage program infrastructure, among other
issues. While changes in the September 24, 2017 version of the proposal
would retain the Health Insurance Marketplace infrastructure as an
option for states to use, considerable barriers to developing and
implementing plans remain. For example, in some states, the legislature
will not meet in 2018.
Implementing new health-care programs takes far longer than the
time frame allowed by the proposal. Take, for example, the process
states already use to contract with managed care organizations to serve
Medicaid beneficiaries. Not including the initial planning period, the
process of developing a request for proposals, soliciting and reviewing
bids, working with plans to develop new products, and enrolling
beneficiaries into plans often takes 18 months or longer. It is very
possible that the time constraint alone means that some states will be
unable to use some or all of their allotments.
The Proposal Would Not Stabilize the Insurance Market in the Short
or Long Term. The proposal fails to fund the cost-sharing reductions
(CSRs) in the short term (2018 and 2019), while providing a separate
fund to help stabilize the insurance markets in 2019 and 2020 (but not
2018). CBO previously estimated that failure to fund the CSRs in 2018
would increase premium rates by 20 percent and increase the federal
deficit by $6 billion that year.
Without CBO Analysis, it Is Impossible to Assess Fully the Impact of
This Proposal. The proposed changes to the health-care system included
in this proposal may alter dramatically how millions of Americans get
health-care coverage and how they access care. Beyond those at risk of
losing coverage, the impact of these changes would be felt throughout
the health-care system. Without a full CBO analysis, no one fully
understands the consequences--both intended and unintended--of this
proposal.
CONCLUSION
Health care coverage is vitally important to working Americans and
their families. They rely on hospitals and health systems to provide
them with access for their essential health-care needs, including the
full range of preventive to critical, life-
saving services. Without coverage, access to these services is at risk,
and, with it, the quality of life and health of our communities. This
proposal would strip hundreds of billions of dollars from the health-
care system and put coverage at risk for some of the nation's most
vulnerable.
We urge the Senate to protect our patients and reject this proposal. We
remain committed to working with you on positive reforms to the health-
care system.
______
American Lung Association
1331 Pennsylvania Avenue, NW, Suite 1425 North
Washington, DC 20004
Ph: 202-785-3355 F: 202-452-1805
September 22, 2017
The Honorable Orrin Hatch
Chairman
Committee on Finance
U.S. Senate
Washington, DC 20510
Dear Chairman Hatch:
The American Lung Association appreciates the opportunity to submit
testimony for the record on the Graham-Cassidy healthcare bill. The
American Lung Association strongly opposes this bill and urges the
Senate to reject it.
The Lung Association believes that any changes to current law should
prioritize preserving quality and affordable healthcare coverage for
all Americans. Instead of proceeding with this legislation, we urge the
Finance Committee to return to its bipartisan efforts on the Children's
Health Insurance Program and proceed in a similar, bipartisan effort to
improve our nation's current healthcare system.
In March of 2017, the American Lung Association and other leading
national health groups released a set of joint principles that our
organizations believe should guide any healthcare legislation. The
three tenants--affordability, accessibility and adequacy of healthcare
coverage--must be incorporated into any proposal to alter the current
system. Unfortunately, the Graham-Cassidy bill does not provide these
three elements and instead, will negatively impact patients' access to
adequate and affordable healthcare.
Protecting People With Pre-Existing Conditions
Ensuring patients have adequate and affordable healthcare is critical
to any healthcare reform bill. As an organization representing lung
disease patients, we recognize that it is of utmost importance. Lung
diseases such as asthma and COPD can be managed, but patients need to
have regular clinical services and medication. Patients must be able to
afford health insurance premiums and have plans offered.
Current law protects patients with preexisting conditions in a number
of vital ways. First, it prohibits denying insurance to people with
pre-existing conditions and it prohibits charging people and families
with pre-existing conditions more for premiums than healthy people.
Current law also defines a basic set of 10 benefits that must be
covered by qualified health plans--these are the essential health
benefits (EHB).
The EHB requirements ensure plans cover a baseline of services, so that
all patients have access to the appropriate care when they need it.
Since plans are required to cover a baseline of benefits, patients
don't need to pay more if they are sick to a plan that covers their
illness.
The proposed Graham-Cassidy bill would give the Centers for Medicare
and Medicaid (CMS) a new and expansive waiver authority to allow states
to definite what qualifies as an EHB. This opens the door for insurance
companies to provide different tiers of coverage; charging sick
patients more for a plan that covers their illness--a point that was
made by insurance company Blue Cross Blue Shield in its statement
opposing the Graham-Cassidy bill this week.\1\ This is likely to make
insurance unaffordable for people with pre-existing conditions, which
is unacceptable for lung disease patients.
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\1\ Blue Cross Blue Shield Association. (2017). Blue Cross Blue
Shield Association Statement on Graham-Cassidy Health Care Reform
Proposal [Press Release]. Retrieved from https://www.bcbs.com/news/
press-releases/blue-cross-blue-shield-association-statement-graham-
cassidy-health-care-reform.
In state-granted waivers, plans would no longer be required to cover
EHBs including prescription drug coverage and can re-impose annual and
lifetime caps on coverage, which negatively impact patients with
illnesses such as lung cancer, asthma and COPD who may rely on costly
medications to manage their conditions. This would undermine any form
of meaningful coverage for patients with pre-existing conditions. We
should not return to an insurance market that often excluded those who
needed coverage the most.
State Flexibility/Market-Based Health Care Grant Program
Current law allows state flexibility to create state marketplaces and
test innovative ideas for the private marketplace through the 1332
waiver process. This process requires states to work with their
legislature and the federal government to design innovate ideas. The
current process has built-in protections for patients.
The 1332 waiver process requires soliciting and responding to public
comment. This gives patients and consumers the ability to provide
feedback on system changes that will impact their healthcare.
Additionally, there are four guardrails around 1332 waivers: states are
required to show how the waiver program will not increase the number of
people uninsured, not increase healthcare costs, not lower the quality
of the coverage and not add to the federal deficit.
The current waiver program allows for states to design programs that
work best for their states, but still provide patients with the
protections to receive the healthcare they need. For lung disease
patients, these protections are critical. They provide that patients
receive the treatments they need to manage their diseases.
The Graham-Cassidy bill does not require states to ensure there are
adequate patient protections in place. As mentioned before, there is no
federal oversight in the new waiver program that would be created by
this bill and states only need to have proposals that do not add to the
deficit.
Under Graham-Cassidy, states will be allowed to change how much
premiums can vary based on age, potentially making insurance
unaffordable for older Americans. The Congressional Budget Office (CBO)
previously found if states were allowed to increase the rating to a 5:1
ratio, the annual cost of premiums could increase to $20,500 for a 64-
year-old buying a silver plan. A premium at this level would price far
too many people out of the insurance market and is unacceptable.
In order to fund this new waiver program, the Graham-Cassidy bill will
siphon the money that is currently funding Medicaid expansion in the 31
states and the District of Columbia (DC) that chose to expand the
Medicaid program. This punishes states that implemented the Affordable
Care Act (ACA) as it was designed. Every state had and still has the
opportunity to expand their Medicaid program and receive an enhanced
Medicaid match--and with it, ensure more of its citizens have quality
and affordable healthcare. We strongly recommend ALL states expand
Medicaid to increase the number of people with health coverage.
Instead, the Graham-Cassidy bill moves in the wrong direction and
reduces the number of people with health coverage. It is harmful to
millions of patients to take money away from a program that provides
healthcare to low-income individuals. Congress should work with states
and CMS to encourage every state to expand to increase the number of
people with healthcare coverage.
Market Stabilization
The proposed bill would destabilize the health insurance market place.
The
Graham-Cassidy bill repeals the Advanced Premium Tax Credits (APTC),
which help families with incomes up to 400 percent of the federal
poverty level pay for insurance premiums. The bill would also remove
the individual and employer mandate that encourages people to buy
insurance. And lastly, the bill does not fund the cost sharing
reductions (CSRs). The removal of these three provisions spell disaster
for state marketplaces. Without a robust marketplace, patients will not
have any opportunity to purchase coverage.
Repealing the APTCs will make it more expensive for lower-middle class
families to purchase health insurance. By foregoing health insurance,
patients will not be able to access preventive services, such as
immunizations, lung cancer screenings and tobacco cessation treatments.
Without preventive services, there is a much higher likelihood of
disease and that disease having a worse prognosis. Patients with health
coverage are better able to manage their chronic disease and avoid
costly emergency room care and hospital admission.
In addition, failing to pay the CSRs is irresponsible. These payments
allow insurers to reduce cost-sharing for people with incomes less than
250 percent of the federal poverty level. Lung diseases can be
expensive to treat, but they can be managed. CSR payments allow lower
income people get the treatment they need, allowing lower income
patients to not only have coverage, but have actual healthcare.
Medicaid
The Graham-Cassidy bill would make the deepest cuts to the Medicaid
program since its inception by implementing a per-enrollee cap starting
in 2020, threatening the healthcare of 68 million low-income patients
who depend on the program for healthcare. The implementation of a per-
capita cap would significantly cut federal funding to states across the
board and place a huge cost-sharing burden on states. Between 2020 and
2026, states would lose $53 billion in Medicaid funding. The strain on
state budgets pressures states to make difficult decisions to limit
their Medicaid spending. States would be forced to cut services, reduce
eligibility or increase cost-sharing for their Medicaid program to keep
costs down.\2\
---------------------------------------------------------------------------
\2\ Garfield, R., L. Levitt, R. Ridowitz, and G. Claxton.
(September 21, 2017). State-by-State Estimates of Changes in Federal
Spending on Health Care Under the Graham-Cassidy Bill. Kaiser Family
Foundation. Retrieved from http://www.kff.org/health-reform/issue-
brief/state-by-state-estimates-of-changes-in-federal-spending-on-
health-care-under-the-graham-cassidy-bill/?utm_cam
paign=KFF-2017-sept-21-GrahamCassidy-state-
analysis&utm_source=hs_email&utm_medium=
email&utm_content=56569375&_hsenc=p2ANqtz-
8zPzKBNCEcMSoTS44BvZ5dEMU9V3hSK5Dh
9szFGzXXFfUfDR4tvoitcSuiaJ7zaC3g_Xt0qSoX3yWlv88SobKzecl8pQ&_hsmi=5656937
5.
Medicaid is an important source of coverage for patients with serious
and chronic health needs, especially those living with lung disease
like asthma. Nearly half of children with asthma are covered by
Medicaid or CHIP. Medicaid cuts would lead to fewer people with lung
diseases having quality and affordable coverage, especially if services
are cut. Medicaid may no longer cover the care and treatments they
need, including breakthrough therapies and technology that represent a
new lease in life. A per capita cap will only exacerbate the downward
pressure on Medicaid budgets and will further reduce access to
treatments for patients.
Medicaid Expansion
Medicaid expansion has been crucial in expanding coverage to more than
15 million Americans, half of whom are permanently disabled, have
serious health conditions or in fair or poor health, and approximately
a third of whom smoke. The Graham-Cassidy bill would end federal match
funding for Medicaid expansion and marketplace subsidies in 2020, and
reallocate the funding to states through smaller block grants. These
block grants provide states flexibility in choosing to use it for
health coverage or other healthcare purposes, but do not guarantee
coverage or financial assistance for individuals. The block grant
funding is also insufficient to maintain current coverage levels.
Overall, states would lose $107 billion. Individually, states stand to
lose up to $55 million if they expanded Medicaid. After 2026 no
additional funding for this population is provided.\3\
---------------------------------------------------------------------------
\3\ Garfield, R., L. Levitt, R. Ridowitz, and G. Claxton.
(September 21, 2017). State-by-State Estimates of Changes in Federal
Spending on Health Care Under the Graham-Cassidy Bill. Kaiser Family
Foundation. Retrieved from http://www.kff.org/health-reform/issue-
brief/state-by-state-estimates-of-changes-in-federal-spending-on-
health-care-under-the-graham-cassidy-bill/?utm
_campaign=KFF-2017-sept-21-GrahamCassidy-state-
analysis&utm_source=hs_email&utm_medi
um=email&utm_content=56569375&_hsenc=p2ANqtz-
8zPzKBNCEcMSoTS44BvZ5dEMU9V3hSK
5Dh9szFGzXXFfUfDR4tvoitcSuiaJ7zaC3g_Xt0qSoX3yWlv88SobKzecl8pQ&_hsmi=5656
9375.
Such a substantial loss in funding would most certainly impact the
coverage of Medicaid expansion patients, including those with lung
disease. It is only logical that states would be forced to cover fewer
services or fewer people with less money. Additionally, seven states
have ``trigger laws'' that would effectively eliminate Medicaid
expansion immediately or soon after the expansion match rate is
eliminated. Patients in these states would lose their healthcare
coverage without any other options. The elimination of Medicaid
expansion coupled with the elimination of subsidy assistance in the
marketplace would result in significant coverage losses.
Prevention and Public Health Fund
The ACA dedicated funding for prevention and public health--in an
attempt to improve the health of Americans and reduce the number of
Americans with chronic disease. The Prevention and Public Health Fund
(Prevention Fund) has allowed the Centers for Disease Control and
Prevention (CDC) to increase its reach, working with patients to
prevent disease. Prevention is almost always less expensive than
treatment and is a good investment for patients. The Prevention Fund
allowed for the designation of more smoke free public spaces, helping
ensure people, including kids with asthma breathe clean air. It is
responsible for funding the Tips From Former Smokers Campaign, which
has helped 500,000 Americans quit smoking. The Prevention Fund
currently comprises 12 percent of CDC's budget and is critical in
ensuring that CDC can continue its important and life-saving work.
The Graham-Cassidy bill threatens the health of far too many lung
disease patients. It jettisons key patient protections that individuals
afflicted by lung disease depend on in order to breathe. It is
irresponsible to move forward on this bill, as it does not protect
patients. The American Lung Association urges Congress to continue the
important bipartisan effort to improve our healthcare system rather
than advancing the Graham-Cassidy bill which would eliminate coverage
for many Americans and devastate patients with pre-existing conditions.
The American Lung Association stands by, ready to work with you on
legislation to ensure all Americans have access to affordable and
adequate healthcare coverage.
Sincerely,
Harold P. Wimmer
National President and CEO
Consensus Healthcare Reform Principles
Today, millions of individuals, including many with preexisting health
conditions, can obtain affordable healthcare coverage. Any changes to
current law should preserve coverage for these individuals, extend
coverage to those who remain uninsured, and lower costs and improve
quality for all.
In addition, any reform measure must support a health care system that
provides affordable, accessible and adequate healthcare coverage and
preserves the coverage provided to millions through Medicare and
Medicaid. The basic elements of meaningful coverage are described
below.
Health Insurance Must Be Affordable--Affordable plans ensure patients
are able to access needed care in a timely manner from an experienced
provider without undue financial burden. Affordable coverage includes
reasonable premiums and cost sharing (such as deductibles, copays and
coinsurance) and limits on out-of-pocket expenses. Adequate financial
assistance must be available for low-income Americans and individuals
with preexisting conditions should not be subject to increased premium
costs based on their disease or health status.
Health Insurance Must Be Accessible--All people, regardless of
employment status or geographic location, should be able to gain
coverage without waiting periods through adequate open and special
enrollment periods. Patient protections in current law should be
retained, including prohibitions on preexisting condition exclusions,
annual and lifetime limits, insurance policy rescissions, gender
pricing and excessive premiums for older adults. Children should be
allowed to remain on their parents' health plans until age 26 and
coverage through Medicare and Medicaid should not be jeopardized
through excessive cost-shifting, funding cuts, or per capita caps or
block granting.
Health Insurance Must Be Adequate and Understandable--All plans should
be required to cover a full range of needed health benefits with a
comprehensive and stable network of providers and plan features.
Guaranteed access to and prioritization of preventive services without
cost-sharing should be preserved. Information regarding costs and
coverage must be available, transparent, and understandable to the
consumer prior to purchasing the plan.
______
February 2, 2017
Dear Senators and Representatives:
Our organizations write to ask for your support for ensuring access to
healthcare for the more than tens of millions of Americans living with
or at risk for lung cancer. As Congress moves forward with its
discussions regarding healthcare, we ask that you recognize those
impacted by lung cancer need access to quality and affordable
healthcare.
Lung cancer is the nation's leading cause of cancer death of women and
men, killing more than 158,000 Americans each year. In 2016, an
estimated 224,000 Americans were diagnosed with lung cancer,
representing about 13 percent of all cancer diagnoses. The 5-year
survival rate for lung cancer is 55 percent for people whose cancer is
detected when the disease is localized in the lungs; however, only 16
percent of lung cancer cases are diagnosed at this early stage. For
lung cancer that has already spread, the 5-year survival rate is only 4
percent.
To help improve these often-grim statistics, in the last 2 years, the
Food and Drug Administration has approved eight new drug therapies for
the treatment of lung cancer--giving new hope to patients and their
families. Many lung cancer patients are alive today because of key
healthcare protections currently in effect that eliminated pre-existing
condition prohibitions, lifetime and annual benefit limits, coverage
rescissions and access to preventive services, including lung cancer
screening for individuals at high risk and smoking cessation
treatments. Together these protections ensure lung cancer patients have
access to new break-through treatments and early detection. Our
organizations oppose attempts to weaken or eliminate any of them.
A stable and affordable insurance marketplace is vital to lung cancer
patients and their families. Instability in the marketplace because of
the unknown will jeopardize affordability and access, especially in the
individual marketplace. We also recognize that proposals that only
guarantee health insurance for those who are able to retain continuous
coverage and that may also impose waiting periods on those who do not
retain such coverage would place barriers to access. Given the
disabling impact cancer has on a person's life and ability to work,
these provisions could put patients with lung cancer at risk for losing
their care.
We are committed to working with you to ensure that our nation's
healthcare system will protect individuals with lung cancer and ensure
they have access to quality and affordable healthcare.
Thank you.
Sincerely,
American Lung Association Lung Cancer Alliance
Addario Lung Cancer Medical
Institute Bonnie J. Addario Lung Cancer
Foundation
Cancer Support Community Cancer Survivors Against Radon,
Inc. (CanSAR)
CancerCare Caring Ambassadors Program, Inc.
Citizens for Radioactive Radon
Reduction, Inc. Dusty Joy Foundation (LiveLung)
Free ME From Lung Cancer Free to Breathe
Lung Cancer Circle of Hope Lung Cancer Initiative
Lung Cancer Research Council Lung Cancer Research Foundation
LUNGevity Foundation Respiratory Health Association
Rexanna's Foundation for Fighting
Lung Cancer Upstage Lung Cancer
______
American Nurses Association (ANA)
8515 Georgia Avenue
Silver Spring, MD 20910
Introduction
On behalf of our members and the 3.6 million Registered Nurses, the
American Nurses Association (ANA) would like to thank Chairman Hatch
and Ranking Member Wyden for having a hearing on the Graham-Cassidy
proposal. The hearing will highlight the critical role healthcare
plays--and will continue to play--in the lives of millions of
Americans. However, the current proposal would create devastating cuts
to the current American healthcare system, resulting in a loss of
coverage for millions of Americans--as a result, ANA opposes the
Graham-Cassidy proposal.
As the largest and most trusted healthcare profession, nurses
directly see the effects of health system reform on patient
care. ANA denounces the latest Senate proposal as its worst
yet. This plan rips coverage from millions of Americans, guts
Medicaid, kills pre-existing conditions protections, and would
have devastating consequences for patients. Patients deserve
better and we won't rest until they get it. --ANA President
Pamela F. Cipriano, Ph.D., RN, NEA-BC, FAAN.
As written, the legislation would make deep cuts to Medicaid, ending
the Affordable Care Act's (ACA) expansion and fundamentally changing
the program to a per-
capita block grant financing system. In addition, the bill would erode
critical consumer protections for pre-existing conditions and essential
health benefits. These costs would result from the absence of a
streamlined standard for states, and the potential absence of
preparedness and health system development in states. Lastly, the
proposal would wipe out subsidies for the purchase of private health
coverage. The proposal fails to meet ANA's principles for health system
transformation.
Tarik Khan--I am a Nurse Practitioner (NP) living in
Philadelphia. This bill will reverse all of the protections
that we got with the ACA. The ban on annual and lifetime limits
has been gotten rid of. They got rid of essential health
benefits, there is a reason why they are called ``essential''
health benefits, and they are getting rid of them completely.
In addition, pre-existing conditions--if you have a pre-
existing condition, you are going to have to pay exponentially
more for healthcare, which is not fair. I have patients in
Philadelphia who are going to lose their health insurance.
Moreover, million are going to lose their Medicaid. As an NP it
is something that I can't let happen. I took a pledge to
advocate for my patients and to look out for their general
welfare. This bill goes against all of that, so I am here to
advocate for nursing and our patients.
Joyce Wilson--I am a Nurse Practitioner. I live and work in
rural West Virginia with West Virginia Nurses Association and
ANA advocating for senators to vote no on this proposal,
because it's going to take coverage away from patients in West
Virginia. It's especially essential in West Virginia because
except for New York, we have the second most expanded Medicaid
in the nation, so 170,000 people got coverage there for the
first time in their life. In West Virginia, we are usually in
the top five of the most ``unhealthy states'' in the nation,
but now we have a chance to turn that around. We have people
that are getting their A1Cs under control, getting their blood
pressures under control, their heart disease under control. So
it's absolutely essential that we do not vote for this bill,
and I hope that you'll come see us in West Virginia. We have
other great things, we have beautiful mountains, and we have
rivers, beautiful people. Therefore, we hope that you will come
and see us and we hope that you will vote no to take away our
healthcare.
Karen Brown--I'm a Registered Nurse, and I live and work in
Lynchburg, VA. I also represent the Virginia Nurses
Association, as I am the chapter president for chapter 3.
Currently, the healthcare covers essential health benefits--
like wellness checkups, prescription drug coverage, maternal-
child care, substance abuse treatments, the list is long. With
the new healthcare bill that is being proposed, essential
health benefits could be taken away, and that affects every
single one of us. It impacts you, your family, your health, and
your community.
Medicaid Cuts and Elimination of Medicaid Expansion
The per-capita limits on Medicaid funds for states threaten excessive
strain on state budgets and reduced coverage for the most vulnerable.
The per-capita limits directly affect individuals with multiple complex
conditions. Limiting the federal support for these patients will
cripple states' financial stability. Without the guarantee of federal
funds for all Medicaid enrollees, patients will face poorer healthcare
outcomes and may potentially lose coverage altogether. While the ANA
supports cost sharing and the economic use of healthcare resources, we
believe that converting the Medicaid program to a block grant would
unduly restrict access to healthcare services to the nation's most
vulnerable citizens and would represent a roll back of the effort to
ensure access to quality healthcare for all Americans.
The Graham-Cassidy bill would have a devastating impact on Americans
who rely upon Medicaid for healthcare coverage. Roughly 70 million
Americans rely on Medicaid for critical healthcare services in a given
year. Many of these individuals are children or are elderly, disabled,
low-income, or a combination of the three. In addition, millions of
Medicaid recipients are able-bodied adults who do, in fact, hold steady
employment and provide for families; close to two-thirds of Medicaid
recipients are employed. The expansion (by most states) of Medicaid
eligibility to Americans living just above the federal poverty level
has had a major impact on the number of uninsured Americans and has
provided needed healthcare services to individuals with complex and
chronic diseases, including mental health and substance use disorders.
In short, Medicaid is a vital source of healthcare services for
American citizens and has improved the lives of millions of Americans.
Medicaid is also an example of a successful state federal partnership
and has allowed states the flexibility to run innovative healthcare
programs--under broad federal guidelines--which best serve the unique
needs of their citizens.
The Graham-Cassidy bill would, however, not only undo the progress made
under Medicaid expansion, but would significantly lessen the ability of
Medicaid to provide adequate healthcare services. The bill proposes to
freeze Medicaid expansion immediately, and would prohibit all states
from keeping expansion in 2020 and beyond. This bill would effectively
seize healthcare coverage from the nearly 11 million Americans who have
gained coverage through Medicaid expansion since 2014. Furthermore, the
bill would limit the amount of federal money available to state
Medicaid programs for other populations, including the elderly,
disabled, and children by imposing a per capita cap system and giving
states the option to convert their Medicaid programs into block grants.
The growth in funding levels proposed by the bill would not
realistically meet the needs of the Medicaid population, and would put
medical care, nursing home care, home- and community-based services,
and other services and supports at risk.
Several reports issued in the past 2 days have reiterated the enormous
impacts of these Medicaid changes. In particular, states that have
expanded Medicaid, including Alaska, Oregon, Delaware, and Washington,
would face significantly higher cuts of 25 percent or more between 2020
and 2026. These cuts would be even starker past 2026, after which
funding is not appropriated and states would experience a fiscal cliff,
adding to the swirl of uncertainty created by this bill. What is
crystal clear, however, is the fact that the Medicaid provisions
proposed in this bill are enormous and would endanger the healthcare of
millions of Americans--including children, the elderly, and the
disabled. These proposed changes to the Medicaid program go against all
of ANA's principles of health system transformation and would be an
unmitigated disaster with respect to the health of the nation.
Impact on Insurance Premiums
The Graham-Cassidy bill proposes major changes to the U.S. healthcare
system, including the repeal of the individual mandate, premium tax
credit subsidies, and cost-sharing reductions. The bill also proposes
to allow states to waive requirements related to essential health
benefits, medical underwriting, and age rating, among others. While
Graham-Cassidy nominally keeps in place provisions of the ACA, it makes
it much easier for states to seek waivers to opt out of these
requirements. While this could potentially make premiums slightly less
expensive for some segments of the population, it would adversely
affect some of the most vulnerable Americans: those with pre-existing
conditions. While states would not be permitted to seek a waiver of the
guarantee issue requirement under current law, the other provisions of
law that they could waive could essentially price people with pre-
existing conditions out of the market. Insurers would be able to raise
premiums based on an individual's medical history while at the same
time excluding certain benefits necessary to that individual's care. In
essence, health insurance would be pointless and unattainable. Further,
given the erosion in funding under the plan's Market-Based Health Care
Grant Program, states would have less of an ability to assist
individuals with pre-existing condition or to those with low-incomes.
This bill would in essence allow for the creation of bifurcated
healthcare systems in individual states and would negatively affect the
most vulnerable populations of Americans. This once again goes against
ANA's principles of health system transformation and moves away from
creating an equitable system for all Americans.
Programmatic and Implementation Concerns
The Graham-Cassidy bill would also put an impossible burden on states
when it comes to implementation of its provisions. The bill gives very
broad policy latitude to states when it comes to their own state health
systems and the implementation of such. However, healthcare is
complicated. States must decide the types of systems they want to
implement, the parameters of those systems, and then implement those
systems. Implementation includes contracting, system building, etc.
This is an incredibly complicated and long-term process; the Graham-
Cassidy bill, however, gives states a 2-year window to accomplish all
of this without so much as a mention of any federal aid or guidelines.
This is a Herculean task for any state; legislative schedules and other
policy priorities complicate it further. It is clear that this bill
cares little about the meaningful provision of care in the states. Such
a limited and rushed timeframe would be detrimental to the effort of
implementing the already flawed policy proposals in this bill.
Pre-Existing Conditions and Essential Health Benefits
The Graham-Cassidy proposal weakens the pre-existing conditions
protections included in the ACA. While the requirement for coverage for
pre-existing conditions remains, patients with such conditions may face
higher premium costs. The proposal weakens the standards for essential
health benefits, and limits consistency of regulations on a state-by-
state basis. These changes are in direct conflict with ANA principles
that support a consistent and clear set of essential health services
for all citizens and residents.
The ACA has incentivized the use of preventive services in order to
ensure that Americans receive the care they need, when they need it--
this not only prevents more complex, chronic, and serious health
conditions in the long term, but also saves money on patient care. The
Graham-Cassidy proposal repeal would strip these incentives and instead
put up barriers to receiving critical preventive services.
Justin Gill, Registered Nurse, and Nurse Practitioner, has seen the
effect of pre-
existing conditions on his own family's health. Before the ACA, Justin
was able to recall when premiums and costs were extremely high for his
parent's, both of whom had pre-existing conditions. Justin's family had
to deal with premiums above $1,000 dollars per month, with out of
pocket costs up to $10,000 dollars. His family faced serious financial
strain as a result of discrimination for pre-existing conditions. His
family avoided regular preventative visits, because of the high out-of-
pocket costs. After the Affordable Care Act, his parents were able to
access more affordable health insurance without questions related to
pre-existing conditions.
Because of this, Justin's father was able to utilize his insurance, and
was less afraid to have his conditions evaluated. His father was seen
for problems with chest pain, and required an open-heart surgery.
Because of tax subsidies and lower out-of-
pocket costs, Justin's family avoided crushing medical bills. Justin
saw the irony of his career goals and his family's previous struggles.
``I remember going through school to help serve the healthcare needs of
others, yet I saw the burden of discrimination of pre-existing
conditions in my own family.'' As a Nurse Practitioner, he has also
been able to see the impact on his own patients. ``I have seen newly
insured patients that had access to life saving preventative services
as a result of the ACA.''
Pam Cipriano--I am a Registered Nurse and president of the
American Nurses Association. I carry around with me this list
of ESSENTIAL HEALTH BENEFITS because people don't understand
what they are. Benefits like PRESCRIPTION DRUG COVERAGE mean my
elderly neighbor doesn't have to tell the pharmacist, ``I can't
pick up my heart medicine because I can't afford it.'' These
benefits provide ADDICTION TREATMENT to help families coping
with the heartbreak and overdose deaths addiction often leaves
in its wake. Guaranteed MENTAL HEALTH SERVICES means my
patients can get the help they need long before their
depression spirals into suicide. MATERNITY AND NEWBORN CARE
means pregnancy is no longer a pre-existing condition, and that
every new mother and her infant get the care they need--before
and after childbirth.
Workforce
Employment in the healthcare sector has grown quickly in recent years
in large part due to changes in the ACA and increased patient caseload.
More nurses working in the healthcare sector allows for higher quality
care delivery and better patient outcomes. The Graham-Cassidy bill
would likely result in massive job losses in the healthcare sector,
affecting the quality of care nurses are able to provide to their
patients.
CNM reimbursements under Medicare Part B cut by 35%.
912,000 healthcare jobs lost by 2019; 1,003,000 healthcare jobs
lost by 2023.
RN/APRN job losses: above average employment, gains by 2015 and
2016 total 107,996 additional jobs (not counting self-employed and
supervisory positions not included in BLS OES.)
ANA Principles of Health System Transformation
Ensure universal access to a standard package of essential healthcare
services for all citizens and residents. This includes:
An essential benefits package that provides access to
comprehensive services, including mental health services.
Prohibition of the denial of coverage because of a pre-existing
condition.
Inclusion of children on parent's health insurance coverage
until age 26.
Expansion of Medicaid as a safety net for the most vulnerable,
including the chronically ill, elderly, and poor.
Optimize primary, community-based and preventive services while
supporting the cost-effective use of innovative, technology-driven,
acute, hospital-based services. This includes:
Primary healthcare that is focused on developing an engaged
partnership with the patient.
Primary healthcare that includes preventive, curative, and
rehabilitative services delivered in a coordinated manner by members of
the healthcare team.
Removing barriers and restrictions that prevent RNs and Advanced
Practice Registered Nurses (APRNs) from contributing fully to patient
care in all communities.
Care coordination services that reduce costs and improve
outcomes with consistent payment for all qualified health professionals
delivering such services, including nurses.
Encourage mechanisms to stimulate economic use of healthcare services
while supporting those who do not have the means to share in costs.
This includes:
A partnership between the government and private sector to bear
healthcare costs.
Payment systems that reward quality and the appropriate,
effective use of resources.
Beneficiaries paying for a portion of their care to provide an
incentive for the efficient use of services while ensuring that
deductibles and co-payments are not a barrier to receiving care.
Elimination of lifetime caps or annual limits on coverage.
Federal subsidies based on an income-based sliding scale to
assist individuals to purchase insurance coverage.
Ensure a sufficient supply of a skilled workforce dedicated to
providing high quality healthcare services. This includes:
An adequate supply of well-educated, well-distributed, and well-
utilized registered nurses.
Increased funding, whether grant or loan repayment based, for
programs and services focused on increasing the primary care workforce.
Funding to elevate support for increasing nursing faculty and
workforce diversity.
Conclusion
Nurses provide care in virtually every healthcare setting from cradle
to grave, providing expert, compassionate healthcare services for
people throughout all stages of life. ANA has asked the Administration
and Congress repeatedly to keep our patients' access to affordable,
quality care foremost in their discussions over how to improve our
nation's healthcare system. It is for the reasons laid out above that
that the American Nurses Association strongly opposes the Graham-
Cassidy proposal. This bill would not improve the U.S. healthcare
delivery system--rather, it would significantly weaken it and would rip
away access to vital healthcare coverage and patient protections that
have been put into place over the last 7 years.
ANA asks the Committee and the Senate to keep our patients' access to
affordable, quality care foremost in their discussions over how to
improve our nation's healthcare system. ANA stands ready to work with
Congress as a constructive voice and positive force for improving
healthcare delivery, coverage, and affordability for the American
people.
______
American Thoracic Society (ATS)
The American Thoracic Society (ATS) appreciates the opportunity to
submit a statement for the record on the Graham-Cassidy bill.
The ATS is a medical professional organization of over 16,000 members
dedicated to the prevention, detection, treatment, cure, and research
of pulmonary disease, critical care illness, and sleep disordered
breathing. ATS members pursue this mission of research, education,
clinical care, and advocacy. The members of the ATS serve a diverse
population of patients with common respiratory diseases like asthma,
COPD and sleep apnea, and less common respiratory diseases like
sarcoidosis, pulmonary hypertension, and LAM. Regardless of the
disease, all our patients benefit from having affordable health
insurance. For many of our patients, it is literally a matter of life
and death. It is with our experience as health care providers and our
concern for the patients who we treat that we offer the following
comments.
The ATS has serious concerns with the Graham-Cassidy legislative
proposal. We note with grave concern that the Senate appears to be
willing to consider this legislation without appropriate committee
hearings, with minimal time for input from the public, including health
care experts and little to no formal input on the likely short and
long-term consequences of the proposal. The ATS is deeply concerned
that the Senate may even consider this legislation without complete
input from the non-partisan Congressional Budget Office. The ATS
expects that the proposed legislative repeal of the individual and
employer mandates will have a large impact on increasing the number of
uninsured Americans in the next several years. While the magnitude of
its effect on rising insurance costs is yet to be estimated by CBO, it
is highly likely that the effects will be significant.
Further, as drafted, the legislation will erode certain basic health
insurance reforms like community rating and lifetime caps that have
improved the private health insurance market for American consumers.
Both the individual mandate repeal and the erosion of private market
reforms will lead to millions of Americans losing health insurance in
the foreseeable future.
That the Senate, the self-proclaimed ``world's most deliberative
body,'' would consider major legislation to fundamentally restructure a
significant part of the U.S. economy and social welfare system without
input from CBO demeans the reputation of the august body.
If enacted, this bill would result in a massive transfer of financial
burden to the states. The ATS notes both Republican and Democratic
governors have expressed their strong opposition to this proposal. The
ATS believes the estimated block grant funding provided under this
proposal is substantially below what is necessary to meet the health
needs of Americans currently covered and represents a massive unfunded
mandate on the states. Further, we note that block grant funding ends
completely in 2026. The ATS is perplexed that the drafters of the
legislation believe that the health care needs of the American public
will end in 2026.
Concerning Medicaid, the Kaiser Family Foundation has estimated that
the bill would cut up to $180 billion between 2020 and 2026 to states
that have expanded Medicaid because the bill would redistribute funds
to non-Medicaid expansion states, and additionally, impose a per-person
cap on all state Medicaid funding. Medicaid expansion states would lose
an average of 11 percent in Medicaid funding, but states such as
California and New York could lose 35 percent of their Medicaid funding
between 2020 and 2026. The reductions and changes to the Medicaid
program under the Graham Cassidy bill would force states to make
significant reductions in Medicaid enrollment, covered benefits and
provider reimbursement. The Graham-Cassidy bill would decimate the
social safety net for millions of Americans, including the disabled and
children. This is unacceptable.
The Graham-Cassidy bill allows states to waive the ACA's essential
health benefits and define their own set of covered benefits without
federal review or approval. Waiving essential health benefits such as
prescription drug coverage, chronic disease management, laboratory
services and maternity and pediatric care will lead to reduced coverage
and much higher costs for needed diagnosis, treatment and preventive
health care services for many Americans. It would result in some low-
income patients with chronic diseases such as COPD being unable to
afford life-
saving treatments and services. All Americans need access to
comprehensive diagnosis, treatment and preventive health care. The ATS
strongly opposes any proposal that weakens coverage of the ACA's
essential health benefits.
Finally, the Graham-Cassidy proposal would repeal the ACA's Prevention
and Public Health Fund, a key source of funding for state and local
services for treatment of tobacco dependence, education efforts, and
other critical public health capabilities for the prevention of chronic
and infectious diseases. The ATS is opposed to any effort to repeal the
Prevention and Public Health Fund.
For the reasons, stated above, the ATS opposes the Graham-Cassidy bill.
We instead urge the Senate to resume the encouraging bipartisan
negotiations efforts led by Senator Alexander and Senator Murray to
craft bipartisan solutions to the shortcomings of the Affordable Care
Act.
______
America's Health Insurance Plans (AHIP)
601 Pennsylvania Avenue, NW, Suite 500, South Building
Washington, DC 20004
and
Blue Cross Blue Shield Association (BCBSA)
1310 G Street, NW
Washington, DC 20005
On behalf of the two largest associations representing the community of
health plans across the United States--America's Health Insurance Plans
(AHIP) and the Blue Cross Blue Shield Association (BCBSA)--we
appreciate the opportunity to comment on the Graham-Cassidy-Heller-
Johnson (GCHJ) legislation, which proposes a block grant approach to
replacing the financial assistance provisions of the Affordable Care
Act (ACA) and also calls for a per capita cap Medicaid financing system
beginning in 2020.
AHIP is the national association whose members provide coverage for
health care and related services to millions of Americans every day.
Through these offerings, we improve and protect the health and
financial security of consumers, families, businesses, communities, and
the nation. We are committed to market-based solutions and public-
private partnerships that improve affordability, value, access, and
well-being for consumers.
BCBSA is a national federation of 36 independent, community-based and
locally operated Blue Cross and Blue Shield companies that collectively
provide health care coverage for one in three Americans. BCBS companies
have an 85-year history providing coverage across all markets in their
local communities and are major providers of health coverage in the
individual market and in the majority of Exchanges.
In previous separate statements for the committee's September 12th
hearing, we outlined our recommendations on steps that can be taken in
the short-term to provide relief to consumers, reduce uncertainty, and
stabilize the individual health insurance market. We continue to
believe it is important for Congress to focus on stabilizing the
individual market for 2018 and 2019 to ensure that Americans have high
quality, affordable coverage options. This approach would help
consumers obtain the coverage and care they need, while providing
Congress and the states an opportunity to fully consider and debate
longer-term reforms.
For today's hearing, our statement focuses on: (1) principles that
Congress should consider in developing legislation that would reform
and affect the coverage and care of millions of Americans; (2) policy
and operational concerns associated with the GCHJ proposal; (3) the
negative impact the bill would have on low-income and vulnerable
populations covered through Medicaid; and (4) initial research findings
showing that this proposed legislation would harm many consumers who
obtain coverage through the individual health insurance market and the
Medicaid program.
Principles for Legislation Addressing Coverage and Care for the
American People
Throughout this debate, our organizations have been committed to engage
in a collaborative, constructive way to address existing challenges in
health care, particularly in the individual market. We have offered
recommendations and solutions that will best deliver on the goals we
share: More choices, lower premiums, help for those who need it, and
lower costs for hardworking taxpayers.
We believe that legislative proposals that would reform and affect the
coverage and care of millions of Americans should meet certain
principles.
First, reforms must stabilize the individual insurance market.
Stability in the individual market has always been challenging, and we
are committed to making this market work. The most important solution
for short-term stability is to fund cost-sharing reduction benefits,
which help millions of lower-income people afford the care they need.
Long term, adopting proven models of success--for example, elements of
the successful Medicare Part D program, such as reinsurance for high
dollar claimants--could deliver greater stability, lower costs for
taxpayers, higher consumer satisfaction, and better health outcomes.
Second, Medicaid reforms must ensure the program is efficient,
effective, and has adequate funding to meet the health care needs of
beneficiaries. Medicaid serves a diverse population of over 70 million
Americans, including some of the most medically vulnerable among us.
Any Medicaid reforms must guarantee that states have sufficient
resources to ensure the continuity of coverage and care that
beneficiaries depend on. State flexibility can improve the program, but
solutions must ensure the sustainability of Medicaid and affordability
in the individual market given how people often move between programs.
Third, reforms must guarantee access to coverage for ALL Americans,
including those with pre-existing conditions. No one should be denied
or priced out of affordable coverage because of their health status. To
ensure that coverage is more affordable for everyone, strong
protections must be coupled with strong incentives that encourage
individuals to maintain continuous coverage.
Fourth, reforms must provide sufficient time for everyone to prepare--
from doctors, hospitals, and health plans to consumers, patients, and
policymakers. States need time to plan, analyze, and make decisions
that could have profound effects on their residents, local health care
systems, and on their state budgets. Once this is finalized, states
need to implement the operational infrastructure, and health plans need
time to develop new coverage options or modify existing ones and have
them approved prior to making them available in the market. Concurrent
with this activity, health care providers need time to understand how
changes will affect them and their patients. And consumers and patients
need time to understand how their coverage will change.
Fifth, reforms should improve affordability by eliminating taxes and
fees that only serve to raise health care costs or reduce benefits for
everyone. Congress delivered relief from the health insurance tax for
2017, and eliminating the tax again for next year will lower premiums
by an average of $158 per member in the individual market.\1\ Not
eliminating the health insurance tax will cost consumers $267 billion
over the next 10 years. Similarly, not eliminating the 40 percent
excise tax will ultimately affect tens of millions of Americans who
receive health benefits through employer-sponsored coverage when it
goes into effect in 2020.
---------------------------------------------------------------------------
\1\ Oliver Wyman, ``Analysis of the Impacts of the ACA's Tax on
Health Insurance in 2018 and Beyond,'' August 8, 2017, http://
www.stopthehit.com/wp-content/uploads/2017/08/Oliver-Wyman-2018-HIT-
Analysis%E2%80%8E-August-8-2017.pdf.
And finally, reforms should rely on the strengths of the private
market, not build a bridge to single payer systems. To best serve every
American, we need both a strong private market and an effective role
for and partnerships with government. Building on the choice,
competition and innovation of the private sector and the strength,
security, and dependability of public programs is a far more effective
solution than allowing states to eliminate private insurance.
Policy and Operational Concerns With the GCHJ Proposal
The GCHJ proposal fails to meet our guiding principles for health
reform. The bill would have negative consequences on consumers and
patients by further destabilizing the individual market; cutting
Medicaid; pulling back on protections for pre-existing conditions; not
ending taxes on health insurance premiums and benefits; and potentially
allowing government-controlled, single payer health care to grow.
Additionally, in our analysis of the bill, we have identified a number
of policy and operational issues that raise serious concerns about the
GCHJ proposal and how it would affect health care coverage and costs
for American families. Below we highlight several highly problematic
concerns--beyond the issues we addressed in our principles above--that
need to be carefully considered.
Unrealistic Expectations for States and Their Programmatic Capabilities
By March 31, 2019--just 18 months after the possible enactment of the
legislation--GCHJ would require all states to establish state-specific
comprehensive health coverage programs to receive federal block grant
funding and prepare to transfer to a per capita cap Medicaid financing
system. This extremely short timeframe for implementation would likely
lead to chaos in both the individual market and Medicaid programs in
all states; these challenges would be layered on top of extensive
funding reductions in a majority of states.
We expect reduced choices for consumers due to the uncertainty about
whether states will be successful in setting up their programs in time
to enroll consumers in coverage for January 1, 2020, and their ability
to attract a broad pool of enrollees into the health insurance market.
Coverage that is available would have to be priced to account for this
uncertainty, basically guaranteeing little if any choice for lower
income consumers. This impact would be even greater in more rural
locations.
Starting in 2020, it is unclear how states would reuse the existing
federal infrastructure to provide tax credits to assist consumers in
purchasing insurance. States would be required to establish a new
administrative infrastructure to conduct eligibility determinations,
deliver subsidies to health plans, facilitate enrollment, and set up
other programs (e.g., high risk pools or reinsurance programs). It is
unlikely that states could use the federal infrastructure to administer
their programs because it was designed to administer federal tax
credits.
The amount of work and resources involved in meeting the requirements
to operationalize the new block grant system cannot be overstated. Not
only does GCHJ fall far short on the needed timeframe to develop and
implement such complex systems, it provides very few resources to do
so. This means that already cash-strapped states would have to invest
significant funds to even get basic functions running by January 1,
2020. It is not clear that any state has the capability of doing so
under these constraints.
No Incentives for Continuous Coverage
Repeal of the individual mandate without a replacement would have an
immediate destabilizing effect on the individual market. GCHJ zeros out
the individual mandate penalties--retroactive to January 1, 2016--
without establishing any alternative approach to promoting continuous
coverage. This would have an immediate impact on the health insurance
market for the remainder of 2017 and for 2018 where rates have already
been approved based on the assumption that the existing mandate would
remain in place.
GCHJ fails to take any steps to ensure that state programs broaden the
risk pool as much as possible, ensuring that individuals of all ages
and health status are insured, not just those who are higher-risk or
costlier to insure. In fact, GCHJ maintains the existing requirement
that health plans offer coverage to everyone that applies (i.e.,
``guaranteed availability'' and ``guaranteed issue''), thus creating
more incentives for people to delay purchasing health care coverage
until they have an immediate health care need. This approach would
drive up costs for everyone. It creates a regulatory environment in
which fewer younger, healthier individuals will be incentivized to get
coverage and the overall pool of people purchasing health insurance
will be weighted more heavily with older and less healthy people. This
will lead to further market instability, higher costs, fewer choices,
and the loss of coverage for millions of Americans.
Constantly Shifting Budgets and Uncertainty for States
The block grant formula proposed by GCHJ would undergo several changes
between 2020 and 2026, and the funding would be completely eliminated
after 6 years unless Congress reauthorizes the funding. This would
result in constantly shifting budgets which, in turn, would create a
high level of uncertainty for states as they try to plan for the
future. Moreover, states would be faced with difficult choices about
which populations to serve, especially since the proposed funding
methodology excludes the working poor--those with incomes under 50% of
the federal poverty level (FPL)--and those with moderate incomes
(between 138-400% FPL).
Starting in 2023, the Secretary of Health and Human Services (HHS)
would be required to use a risk adjustment formula to significantly
adjust block grant funding. It is unclear how HHS could develop a risk
adjustment system across states that would each implement their
programs differently. This would create even more challenges for plans
as they develop and price products.
Even with the required investment for programmatic operations to
account for the new block grant system, the entire program is set to
expire in only 6 years. It is difficult to imagine states, health
plans, and health systems devoting significant resources for a program
whose long-term viability and funding levels are so uncertain.
Uncertainty for Existing ACA Programs That Are Not Modified
The existing ACA risk adjustment program for health plans would remain
in place under GCHJ, but it would become impossible to implement. To
work effectively, risk adjustment requires a uniform set of benefits
and consistent rating approaches to manage against adverse selection.
The very core of GCHJ seeks to remove uniformity in these areas, making
a federal risk adjustment program unfeasible.
Uncertainty for Health Plan Business Planning
Insurers plan several years in advance before making decisions about
their participation in new markets. Under GCHJ, the implementation of
major reforms in 2020 would leave little to no opportunity for health
plans to determine the potential market or rules of operation before
they make decisions about the products they offer. Moreover, states
would have broad flexibility in deciding how to use their block grant
funding. Some of the potential options, including direct payments to
providers and a single-payer structure, would remove any role for
private coverage, thereby taking away valuable coverage options from
consumers.
In addition, since states submit their applications for how they will
use their portion of the market based grants on March 31st of the
preceding year, it is unclear how insurers will know how this affects
the pricing for both individual market products and Medicaid managed
care for the following year given that states and insurers will not
know the grant amount until much later in the year.
Negative Impact on Employer-Sponsored Coverage
While employer-sponsored coverage is not the primary focus of the GCHJ
proposal, it likely would have a negative impact on the 177 million
Americans who get their health insurance coverage through work.
Several factors would cause employees to either lose coverage, face
higher costs, or see a reduction in benefits:
Because states can waive essential health benefits, self-insured
employers would be able to reinstate annual and life-time benefit
limits that were common before the ACA. This would severely impact
employees who have an ongoing need for expensive health care services
and treatments such as chemotherapy.
GCHJ maintains taxes that directly increase consumer costs and limit
benefits, including the ACA health insurance tax and the Cadillac tax--
both of which raise out-of-pocket costs for Americans who get coverage
through work.
Under GCHJ, health care providers would be likely to see more
uninsured patients and would be likely to receive lower reimbursement
rates under the new systems implemented by states. This, in turn, would
cause provider payment rates to increase in other markets--including
the market for employer-sponsored health coverage. This type of cost-
shifting, from public programs to private payers, would increase under
GCHJ since there would be more uninsured patients who are unable to pay
their medical bills and there would be more providers receiving
reimbursement rates that fail to cover their actual costs of delivering
medical care.
Effects on Low-Income and Vulnerable Populations Covered Through
Medicaid
The GCHJ proposal would significantly reduce the federal government's
role in financing health benefits for Medicaid beneficiaries, while
also limiting the funds available to support private coverage options
for individuals with modest incomes who are not eligible for Medicaid.
As we discuss in the next section below, a new analysis from Avalere
estimates that GCHJ would reduce federal Medicaid funding by $713
billion over 2020-2026 and by more than $3.5 trillion over 2020-2036 if
the bill's block grant funding is not reauthorized. The authors
conclude: ``Funding cuts of this magnitude will force states to re-
evaluate their Medicaid programs, including the number of individuals
covered and the generosity of the provided benefits.''
In examining the impact of these cuts, it is important for policymakers
to recognize that the individual market and Medicaid are closely
related with respect to the partial overlap in the populations they
serve. For example, many low-wage employees do not have access to
employer-sponsored coverage and need help accessing affordable
coverage; if their incomes fall due to loss of employment or other
reasons, Medicaid becomes an important safety net.
Conversely, individuals with Medicaid who move up the economic ladder
may lose eligibility and need affordable coverage in the individual
market. Reducing subsidies for their coverage--as GCHJ proposes--would
create incentives for people to remain at an income level that
qualifies for Medicaid coverage and, as a result, have the perverse
effect of discouraging people from lifting themselves up out of
poverty.
Given how the two markets interact with respect to a diverse and often
vulnerable population, Congress should ensure that federal policies are
designed to ensure both the long-term stability and affordability of
the individual market and continued strength and long-term
sustainability of the Medicaid program. The GCHJ proposal fails to meet
these objectives.
Initial Research Findings on the Impact of the GCHJ Proposal
We believe the extensive reforms in the GCHJ proposal should not be
fast-tracked for passage by September 30th. Instead, additional time
should be allowed for the Congressional Budget Office (CBO) to produce
a comprehensive analysis of the bill and for states to fully understand
the proposed financial and structural impact to their individual health
insurance markets and Medicaid programs.
Research findings by several organizations raise important issues and
questions that should be examined more closely before the Senate votes
on the GCHJ bill. Below we highlight a number of these findings, which
are based on legislative language released on September 13th. An
updated bill, released on September 24th, appears to be even more
problematic, proposing to create two separate systems of health
coverage--one for healthy people and another for sick people. This
approach is unworkable in any form and would undermine protections for
those with pre existing medical conditions, increase premiums, and lead
to widespread terminations of coverage for people currently enrolled in
the individual market.
A new study by Avalere estimates that GCHJ would reduce, relative to
current law, federal Medicaid funding by $713 billion over 2020-2026
and by more than $3.5 trillion over 2020-2036, if the bill's block
grant funding is not reauthorized.\2\ For the 2020-2026 time period,
this includes $593 billion in cuts that are attributed to the proposed
block grants and $120 billion that are attributed to the proposed
Medicaid per capita cap system. Avalere estimates that 34 states and
the District of Columbia would experience Medicaid funding reductions
through 2026, and all states would see a reduction in their federal
Medicaid funding by 2036.
---------------------------------------------------------------------------
\2\ Avalere, ``Graham-Cassidy-Heller-Johnson Bill Would Reduce
Medicaid Funds to States by $713B Over the Next 10 Years,'' Chris
Sloan, Richard Kane, September 22, 2017, http://avalere.com/expertise/
managed-care/insights/graham-cassidy-heller-johnson-bill-would-reduce-
medicaid-funds-to-states-by.
While discussing the Medicaid funding cuts that 34 states would
experience in 2020-2026, the Avalere study explains: ``These states
include all expansion states and three states (Arkansas, Iowa, and
Maine) that see large reductions in their traditional Medicaid spending
due to per capita caps. As expansion states are only permitted to use
15% of their block grant allotments in Medicaid, their total Medicaid
---------------------------------------------------------------------------
funding would be substantially reduced.''
Another study, released by Manatt Health, outlines the following
findings: \3\
---------------------------------------------------------------------------
\3\ Manatt Health, ``Update: State Policy and Budget Impacts of New
Graham-Cassidy Repeal and Replace Proposal,'' September 2017, http://
www.statenetwork.org/wp-content/uploads/2017/09/SHVS_Graham-Cassidy-
Sept-2017_Final.pdf.
Over 2020-2026, the block grant proposed by the GCHJ bill would
provide 6.4 percent less federal funding than under current law. By
2026, the gap between current law funding and the proposed block grant
funding would be 8.9 percent. Over 2020-2026, 29 states would
experience, relative to current law, a reduction in federal funding
(with an average reduction of 19 percent) and nine of these states--
Alaska, Connecticut, Delaware, New Hampshire, New Mexico, New York,
Oregon, Vermont, and Washington--would see reductions of 25 percent or
---------------------------------------------------------------------------
more.
Looking beyond 2026, the Manatt study explains: ``States will be at
full financial risk for funding coverage programs and services
developed under the block grant when the grant ends in 2026; there is
no guarantee of whether and at what level federal funding would be
available beginning in 2027.''
Finally, this analysis comments: ``States would have broad latitude
to obtain waivers of ACA provisions, including waivers of ACA benefit
and rating requirements. In states that obtain waivers, individuals
with pre-existing conditions could face substantially higher premiums
or find their policies do not cover essential services.''
An analysis from Fitch Ratings cautions that ``over time even non-
expansion states will face budgetary challenges given the proposed
changes to Medicaid, which will likely accelerate for all states over
time.'' \4\ Fitch states that Medicaid changes in the GCHJ proposal
``could have implications for states' credit quality and for the credit
quality of related public finance entities that depend on state
funding.''
---------------------------------------------------------------------------
\4\ Fitch Ratings, ``Latest ACA Bill Includes Medicaid Repeal and
Replace Provisions for States,'' September 15, 2017, https://
www.fitchratings.com/site/pr/1029238.
While discussing the potential for other state-funded activities to be
affected by Medicaid funding cuts, Fitch states: ``Medicaid changes
that significantly reduce federal funding to states will cause states
to consider a broad mix of spending cuts or revenue increases to
maintain long-term fiscal balance. In a time of already muted revenue
growth, spending cuts could affect K-12 and higher education the most,
as those are the other largest areas of state spending outside of
---------------------------------------------------------------------------
Medicaid.''
An issue brief released by the Kaiser Family Foundation (KFF) provides
estimates--including state-by-state data--on how federal funding for
health benefits would be affected by the GCHJ bill's proposals for a
new block grant program and a Medicaid per capita cap financing
system.\5\ KFF explains that the deepest cuts would be imposed in
states that implemented the ACA's Medicaid eligibility expansion. The
issue brief states: ``There would be a significant redistribution in
federal funding across states under the block grant. Overall expansion
states would lose $180 billion for ACA coverage and non-expansion
states would gain $73 billion over the 2020-2026 period. A typical
Medicaid expansion state would see an 11% reduction in federal funds
for coverage compared to an increase of 12% in a typical non-expansion
state.''
---------------------------------------------------------------------------
\5\ Kaiser Family Foundation, ``State-by-State Estimates of Changes
in Federal Spending on Health Care Under the Graham-Cassidy Bill,''
September 2017, http://files.kff.org/attachment/Issue-Brief-State-by-
State-Estimates-of-Changes-in-Federal-Spending-on-Health-Care-Under-
the-Graham-Cassidy-Bill.
Most recently, the Brookings Institution issued a report that analyzed
the impact on the number of Americans with health insurance coverage
under the GCHJ proposal.\6\ The authors estimate that, in 2018 and
2019, the number of insured Americans would fall by 15 million. With
the transition to the Market-Based Health Care Grant program starting
in 2020 where federal funding for the exchange marketplaces through
APTC, CSR, and BHPs along with a portion of the Medicaid expansion
funding are converted into a block grant, they estimate that the number
of uninsured individuals would rise to around 21 million per year over
the 2021-2026 period. Looking out at the effects on insurance coverage
in 2027 and beyond after the expiration of the block grant funding
program, upwards of 32 million fewer individuals would have coverage.
The authors caution that this estimate may be conservative because it
does not include all of the provisions in the GCHJ proposal, including
the effects of the per capita caps on Medicaid.
---------------------------------------------------------------------------
\6\ ``How will the Graham-Cassidy proposal affect the number of
people with health insurance coverage?'', September 22, 2017, https://
www.brookings.edu/research/how-will-the-graham-cassidy-proposal-affect-
the-number-of-people-with-health-insurance-coverage/.
All of these findings raise serious questions and concerns about the
likely impact of the GCHJ proposal on health care costs and choices for
consumers who buy coverage in the individual health insurance market
and the continued role of Medicaid as a health care safety net for low
income Americans. To answer these questions, we believe it is
critically important for the Senate to allow time for CBO to conduct a
comprehensive analysis of this new legislation before voting on its
approval.
Conclusion
While our organizations cannot support the GCHJ proposal given the lack
of alignment with our principles, we will keep working to find the
right solutions that reflect the commitment we all share: affordable
coverage and high-quality care for every American. By working together,
we can improve health care and deliver the coverage and care that every
American deserves.
______
The Arc of Colorado
1580 Logan St. #730
Denver, CO 80203
http://www.thearcofco.org/
The Arc of Colorado, with 14 local chapters of The Arc throughout the
state, is strongly opposed to provisions reducing access to affordable
health care and to long term supports and services that are included in
the revised bill offered by Senators Lindsey Graham (R-SC), Bill
Cassidy (R-LA), Dean Heller (R-NV), and Ron Johnson (R-WI). This
dangerous legislation uses per capita caps to deeply cut and radically
restructure the traditional Medicaid program that individuals with
intellectual/developmental disabilities rely on to live and work in the
community. It ends Medicaid expansion which has enabled more than
400,000 moderate to low income Coloradans pay for health insurance and
replaces it with a temporary block grant that expires in 2026. It also
gives states the option to end key consumer protections that have
helped people with pre-existing conditions, including people with
disabilities, access the health care services they need.
A recent study by Avalere shows that for 2020 through 2026, 34 states
and DC would see funding cuts--Colorado would lose $6 billion by 2026.
Once the block grant for Medicaid expansion ends in 2027, all states
would see large cuts (the cut in 2027 alone would be $283 billion).
Total cuts to federal funding for coverage would total over $4 trillion
through 2036. Colorado would lose up to $78 billion by that year. Cuts
to the traditional Medicaid program would be more than $1 trillion over
2 decades. And looking at the growth rates by population, federal
funding by 2036 would be 15 percent below current law for people with
disabilities, 31 percent below current law for children, and 37 percent
below current law for non-disabled adults. The need won't go away, so
these cuts would be devastating to state Medicaid systems and mean life
and death to people with disabilities.
Nationwide, Medicaid provides essential services to more than 10
million people with disabilities. People with disabilities rely on
Medicaid for personal care services, specialized therapies, intensive
mental health services, special education related services, and other
needed services that are unavailable through private insurance. With
greatly reduced federal contributions to Medicaid as proposed under the
Graham-Cassidy plan, most states would not be able to make up the
difference.
Medicaid is the main source of funding for over 77% of the supports and
services that individuals with intellectual and/or developmental
disabilities (I/DD) use to live in the community and has been able to
grow because of the widespread bipartisan support. These supports and
services provide dignity to people with I/DD by providing help with
meals, bathing and dressing, toileting, in-home skilled nursing, and
communication support, to name but a few. These supports are critical
to people with disabilities to be able to live their life in the
community. In many cases, they can be the difference between life and
death.
We fear that because home and community based services are optional
services, they will be cut first. States will return to outdated modes
of serving people with disabilities, congregating large numbers of
individuals in facilities with inadequate staffing and no real-life
opportunities.
The Arc of Colorado is disappointed that the bill also retains the $19
billion cut of the enhanced federal match in the Community First Choice
Option, which is a permanent program that provides an enhanced federal
match to any state that chooses the option to provide additional
personal assistance services. Instead, the Senate bill includes a new
home and community based demonstration program. A total of $8 billion
is available over 4 years to a limited number of states. This is a
woefully inadequate response to the deep cuts to Medicaid and the
threat that poses to home and community based services.
The Arc of Colorado is deeply concerned that the Senate is discussing
moving forward without a complete analysis by the independent
Congressional Budget Office (CBO) of the revised bill, known as the
Graham-Cassidy plan. The Arc is also concerned that there have not been
hearings or stakeholder input or a comprehensive effort to understand
the impact of these major changes and the harm it could pose to people
needing health coverage and Medicaid's long term supports.
The lives and independence of Coloradoans with disabilities are on the
line. The Arc of Colorado urges you to oppose the Graham-Cassidy plan
to preserve health care and access to community living provided under
Medicaid.
Marijo Rymer
Executive Director
______
The Arc of Massachusetts
217 South Street
Waltham, MA 02453-2710
T: 781-891-6270
F: 781-891-6271
http://thearcofmass.org/
The Arc of Massachusetts is strongly opposed to provisions reducing
access to affordable health care and to long term supports and services
that are included in the revised bill offered by Senators Lindsey
Graham (R-SC), Bill Cassidy (R-LA), Dean Heller (R-NV), and Ron Johnson
(R-WI). This dangerous legislation uses per capita caps to deeply cut
and radically restructure the traditional Medicaid program that
individuals with I/DD rely on to live and work in the community. It
ends the Medicaid expansion and the affordability provisions to help
people pay for private health insurance, and replaces it with a
temporary block grant that expires in 2026. It also gives states the
option to end key consumer protections that have helped people with
pre-existing conditions, including people with disabilities, access the
health care services they need.
A recent study by Avalere shows that for 2020 through 2026, 34 states
and DC would see funding cuts. Once the block grant for Medicaid
expansion ends in 2027, all states would see large cuts (the cuts in
2026 in Massachusetts would be $14 billion). Total cuts to
Massachusetts federal funding for coverage would total over $93 billion
by 2037. This would mean major reductions in supports and services for
people with disabilities let alone health care. The need won't go away,
so these cuts would be devastating to state Medicaid systems and mean
life and death to people with disabilities.
Nationwide, Medicaid provides essential services to more than 10
million people with disabilities. People with disabilities rely on
Medicaid for personal care services, specialized therapies, intensive
mental health services, special education related services, and other
needed services that are unavailable through private insurance. With
greatly reduced federal contributions to Medicaid as proposed under the
Graham-Cassidy plan, most states would not be able to make up the
difference.
Medicaid is the main source of funding for over 77% of the supports and
services that individuals with intellectual and/or developmental
disabilities (I/DD) use to live in the community and has been able to
grow because of the widespread bipartisan support. These supports and
services provide dignity to people with I/DD by providing help with
meals, bathing and dressing, toileting, in-home skilled nursing, and
communication support, to name but a few. These supports are critical
to people with disabilities to be able to live their life in the
community. In many cases, they can be the difference between life and
death.
We fear that because home and community based services are optional
services, they will be cut first. States will return to outdated modes
of serving people with disabilities, congregating large numbers of
individuals in facilities with inadequate staffing and no real life
opportunities.
The Arc is disappointed that the bill also retains the $19 billion cut
of the enhanced federal match in the Community First Choice Option,
which is a permanent program that provides an enhanced federal match to
any state that chooses the option to provide additional personal
assistance services. Instead, the Senate bill includes a new home and
community based demonstration program. A total of $8 billion is
available over 4 years to a limited number of states. This is a
woefully inadequate response to the deep cuts to Medicaid and the
threat that poses to home and community based services.
The Arc is deeply concerned that the Senate is discussing moving
forward without a complete analysis by the independent Congressional
Budget Office (CBO) of the revised bill, known as the Graham-Cassidy
plan. The Arc is also concerned that there have not been hearings or
stakeholder input or a comprehensive effort to understand the impact of
these major changes and the harm it could pose to people needing health
coverage and Medicaid's long term supports.
The lives and independence of people with disabilities are on the line.
The Arc urges you to oppose the Graham-Cassidy plan to preserve health
care and access to community living provided under Medicaid.
______
The Arc of New Jersey
985 Livingston Avenue
North Brunswick, NJ 08902
T 732-246-2525
F 732-214-1834
http://www.arcnj.org/
The Arc of New Jersey represents people with intellectual and
developmental disabilities (I/DD) and their families who are dependent
on the Medicaid program. With this in mind, we are very concerned by
the Graham-Cassidy-Heller-Johnson Proposal which would threaten the
Medicaid program through cuts ushered in under a Block Grant program
and Per Capita Caps, as well as potentially undermine Essential Health
Benefits (EHBs). The long term supports and services that keep people
in the community would not be possible without adequate funding for
Medicaid and inclusion of EHBs in health insurance plans. In
particular, if the system were to shift to a Block Grant system, which
is currently estimated to provide states with 17% fewer funds for their
Medicaid programs, states would have no choice but to cut services from
their offerings due to a lack of funding. Under the Graham-Cassidy-
Heller-Johnson Proposal, New Jersey will see an approximately $112
billion dollar reduction in funding by the year 2036. As you can
imagine, this would have a devastating impact on people with I/DD
living in our state.
Among the threatened programs, the Graham-Cassidy-Heller-Johnson
Proposal's cuts to Medicaid most directly endangers Home and Community
Based Services (HCBS) because while they are cost effective and
functional, they are not mandatory for states to provide. Additionally,
since most HCBS programs are delivered by Medicaid waivers, there are
already a limited number of spots available, leading to wait lists.
Currently, over half a million people are on waitlists nationwide for
these programs. Since Graham-Cassidy-Heller-Johnson Proposal would cut
Medicaid by hundreds of billions of dollars, waitlists would likely
greatly expand, as states struggle to provide required services to
eligible individuals before they could even begin to move on to
providing optional waiver services, like HCBS, to those who need them.
Along with the Block Grant System, the Graham-Cassidy-Heller-Johnson
Proposal would move Medicaid to a Per Capita Cap system which places
limits on how much the federal government can contribute to a state in
a given year, based on historical data. The rates that the federal
government can contribute do go up every year, but at a significantly
lower rate than how state Medicaid costs are estimated to rise, leaving
states without enough money to cover their Medicaid programs, which
inevitably leads to cuts in service offerings. The bill would also
penalize states who spend above the national average on their Medicaid
program, meaning that states that have residents with greater needs,
more optional benefits, or a higher cost of living, could be hurt. This
will put immense pressure on states to cut services and eligibility,
leaving many individuals with disabilities without vital services.
Finally, this bill threatens pathways to coverage for children with
disabilities. Nearly all states disregard parental income for children
with significant disabilities living at home to provide them Medicaid
coverage. This option, called the ``Katie Beckett program,'' saves
parents from having to place their child in institutional care, as
parental income is automatically disregarded so their child can qualify
for Medicaid. This program, which allows children to receive the care
they need while living at home, has proven to be invaluable for New
Jersey residents and would be at risk under the Graham-Cassidy-Heller-
Johnson Proposal
In addition, the Graham-Cassidy-Heller-Johnson Proposal also threatens
Essential Health Benefits (EHBs) by allowing states to give insurers
the option to waive the coverage of EHBs, which include both mental
health services, and habilitative services. Often times, individuals
with I/DD also have mental health challenges and this is known as dual
diagnosis. Those with dual diagnosis often need a range of services so
that they can live successfully in the community. If a state waives
EHBs such that mental health benefits are excluded altogether from
plans, mental health parity protections are rendered meaningless
because mental health parity only applies if plans offer mental health
benefits. Insurers also have the option not to provide habilitative
services. Even if plans still include mental health protections and
habilitative services, if EHBs are not required by the state and not
included by insurers, insurers could impose lifetime and annual limits
on these services. Habilitation services are likely to be necessary in
the long term for families with children with I/DD. Protection against
lifetime and annual limits only applies to EHBs, so if EHBs are waived,
limits can be implemented. Bringing back lifetime and annual limits
leaves families with insurance that does not meet their needs.
The Graham-Cassidy-Heller-Johnson Proposal will destroy the system as
we know it and the consequences will be both painful and irreversible.
With this in mind, we ask you to please vote against this Proposal when
it comes before you and to do everything you can to beat back any and
all proposed cuts to Medicaid. Instead of moving the system forward,
this legislation will reverse years of progress and advancements and
will reduce the quality of life for individuals with I/DD who already
face significant challenges.
We thank you for your time and consideration. In these critical times,
we ask you to do everything in your power to prevent these proposals
from becoming a reality.
______
The Arc of Pennsylvania
301 Chestnut Street, Suite 403
Harrisburg, PA 17101
T 717-234-2621
http://thearcpa.org/
The Arc of Pennsylvania stands with The Arc of the United States and
the many other organizations opposed to all proposals that reduce
Medicaid funding and specifically, the bill authored by Senators
Lindsey Graham, Bill Cassidy, Dean Heller and Ron Johnson. This
legislation jeopardizes the health care of thousands of Pennsylvanians,
including people with disabilities. For 68 years, The Arc of
Pennsylvania has worked to ensure that children and adults with
developmental disabilities including autism and intellectual disability
receive the supports and services they need, are included in their
community, and have control over their own lives. This bill jeopardizes
all that we have worked for and achieved over the past 68 years.
This proposal while shifting significant responsibility onto states;
institutes a block grant that expires in 2026. Our recent experiences
in Pennsylvania have led us to be wary of block grants. They are often
espoused to offer flexibility however much of the flexibility offered
is already available in the current system and the block grant actually
translates to cuts in funding. The block grant in the Graham-Cassidy
proposal is a significant cut in Medicaid funding to Pennsylvania.
The Arc of Pennsylvania is concerned about the ability of block grants
to adjust when there are changes in needs, such as natural disasters,
health care epidemics, or economic recessions. With a capitation,
legislation, often challenging to pass, would be necessary for Medicaid
to provide additional financial help when the need in Pennsylvania
increases. Pennsylvania's data demonstrates that our population is
aging and the acuity of people receiving disability services is
becoming more severe over time. Certainly, this past year's hurricanes
and the national opioid epidemic have made states more aware of the
critical role of Medicaid.
The Arc has a long history of promoting pre-natal care and we
especially promote the avoidance of drinking alcoholic beverages during
pregnancy. We are very concerned that states would have options
regarding the coverage of essential benefits including pre-natal care.
Understanding the established scientific research regarding the
benefits of early pre-natal care and the impact of addiction treatment
on developing fetuses, we strongly request reconsideration of your plan
and require states to provide this essential health benefit coverage.
In Pennsylvania, our Early Intervention program, serving children birth
through 5 years of age, significant portions of special education, and
our entire adult system for people with disabilities all rely on
Medicaid funding. Cuts to Medicaid impact 722,000 people with
disabilities in Pennsylvania. It is estimated that Pennsylvania alone
will lose $15 billion in federal funding by 2027 if Graham-Cassidy is
passed. This will result in an extreme shift in funding to our state
budget. Our state legislature would be tasked to replace this funding
or be forced to cut services, reduce payments, or completely eliminate
coverage for some of our most vulnerable citizens. Our legislators will
be tasked with very difficult decisions--who is most deserving of
health care? Our children? People with disabilities? People in a mental
health crisis? Those with addictions? Working age taxpayer adults with
disabilities? Our seniors? Our worry is that children born with
disabilities will not receive the critical services they need at an
early age and that adults with disabilities will be relegated to large
congregate facilities if they receive services at all.
Three months into this fiscal year, Pennsylvania still does not have a
state budget. Two years ago, it took 9 months for a state budget to be
finalized. Clearly, with garnering sufficient state resources being an
almost insurmountable challenge, we have to believe that Medicaid cuts
would only exacerbate our already existing 5,000-
person emergency waiting list for persons with intellectual disability.
We appreciate that the Graham-Cassidy bill includes language exempting
children with disabilities from the per capita cap but in Pennsylvania,
we already have a huge cliff effect for those turning 21, transitioning
from entitled children's Medicaid services to unfunded adult services
with long waiting lists.
The Arc of Pennsylvania is deeply disappointed that the Senate is
discussing a move forward without a complete analysis by the
independent Congressional Budget Office. There needs to be sufficient
hearings with stakeholder involvement to provide input on the impact of
the Graham-Cassidy-Heller-Johnson proposal.
We have been communicating with our members throughout the weekend and
continue to hear how they are deeply concerned that their circumstances
have not been adequately listened to or addressed. While imperfect, the
Affordable Care Act (ACA) created many life-saving changes for our
members. The elimination of life time caps, the assurance that they
would not have higher premiums for having pre-existing conditions, and
the guaranteed portability of insurance if they had to change jobs,
were life changing to our members. They want desperately to know that
their legislators understand the impacts of any decision related to
Medicaid and its impact on their lives.
The Arc of Pennsylvania, with over 8,000 members and 33 local chapters,
is our state's largest disability advocacy organization. We work to
protect and enhance the rights of people with disabilities so that they
can live, learn, work, and thrive in their community. We believe that
capitation of Medicaid funding to Pennsylvania threatens the very
disability service system that we have fought so long to build. The Arc
of Pennsylvania urges you to oppose the Graham Cassidy plan and to
preserve health care and access to community living provided under
Medicaid. If you have any questions, please contact Maureen Cronin,
Executive Director, The Arc of Pennsylvania at 717-234-2621 or
[email protected].
______
The Arc Tennessee
545 Mainstream Drive, Suite 100
Nashville, TN 37228
The Arc Tennessee is strongly opposed to provisions reducing access to
affordable health care and to long term supports and services that are
included in the revised bill offered by Senators Lindsey Graham (R-SC),
Bill Cassidy (R-LA), Dean Heller (R-NV), and Ron Johnson (R-WI). This
dangerous legislation uses per capita caps to deeply cut and radically
restructure the traditional Medicaid program that individuals with I/DD
rely on to live and work in the community. It ends the Medicaid
expansion and the affordability provisions to help people pay for
private health insurance, and replaces it with a temporary block grant
that expires in 2026. It also gives states the option to end key
consumer protections that have helped people with pre-existing
conditions, including people with disabilities, access the health care
services they need.
A recent study by Avalere shows that for 2020 through 2026, 34 states
and DC would see funding cuts. Once the block grant for Medicaid
expansion ends in 2027, all states would see large cuts (the cut in
2027 alone would be $283 billion). Total cuts to federal funding for
coverage would total over $4 trillion through 2036. Cuts to the
traditional Medicaid program would be more than $1 trillion over 2
decades. And looking at the growth rates by population, federal funding
by 2036 would be 15 percent below current law for people with
disabilities, 31 percent below current law for kids, and 37 percent
below current law for non-disabled adults. The need won't go away, so
these cuts would be devastating to state Medicaid systems and mean life
and death to people with disabilities.
In Tennessee, there are at least 102,000 people with intellectual and
developmental disabilities and Medicaid (TennCare) is the primary
source of essential health care and long-term services for this
population. Tennesseans with disabilities rely on TennCare not only for
basic healthcare, but also for personal care services, specialized
therapies, intensive mental health services, special education related
services, and other needed services that are unavailable through
private insurance. With greatly reduced federal contributions to
Medicaid as proposed under the Graham-
Cassidy plan, Tennessee wound not be able to make up the difference, no
matter what flexibility is offered. The federal government currently
matches $2 for every $1 Tennessee invests in the TennCare program, and
TennCare is already nationally recognized as one of the most
efficiently run programs in the country.
TennCare is the main source of funding for over 55% of the supports and
services that individuals with intellectual and/or developmental
disabilities (I/DD) use to live in the community and has been able to
grow because of the widespread bipartisan support. These supports and
services provide dignity to people with I/DD by providing help with
meals, bathing and dressing, toileting, in-home skilled nursing, and
communication support, to name but a few. These supports are critical
to people with disabilities to be able to live their life in the
community. In many cases, they can be the difference between life and
death.
Given that home and community based services are optional under
TennCare, they will be the first to be cut from the program. These cuts
will force Tennessee to return to outdated models of service that
segregate large numbers of individuals with I/DD in facilities with
inadequate staffing and no real-life opportunities.
The Arc Tennessee is concerned that the Senate may move forward without
a complete analysis by the independent Congressional Budget Office
(CBO) of the revised bill, known as the Graham-Cassidy plan. We are
also concerned that there have not been hearings or stakeholder input
or a comprehensive effort to understand the impact of these major
changes and the harm it could pose to people needing health coverage
and Medicaid's long term supports.
The lives and independence of people with I/DD are on the line. The
progress we have made the last several decades is in danger of being
completely reversed. The Arc Tennessee urges you to oppose the Graham-
Cassidy plan, to preserve health care and the access to community
living provided under Medicaid, and to work in a bi-partisan manner to
deliver healthcare legislation that goes through the normal
congressional processes.
Submitted on behalf of The Arc Tennessee by Carrie Hobbs Guiden,
Executive Director
______
The Arc of the United States
1825 K Street, NW, Suite 1200
Washington, DC 20006
T 202-534-3700
F 202-534-3731
https://www.thearc.org/
The Arc of the United States (The Arc) is strongly opposed to
provisions reducing access to affordable health care and to long term
supports and services that are included in the revised bill offered by
Senators Lindsey Graham (R-SC), Bill Cassidy (R-LA), Dean Heller (R-
NV), and Ron Johnson (R-WI). This dangerous legislation uses per capita
caps to deeply cut and radically restructure the traditional Medicaid
program that individuals with I/DD rely on to live and work in the
community. It ends the Medicaid expansion and the affordability
provisions to help people pay for private health insurance, and
replaces it with a temporary block grant that expires in 2026. It also
gives states the option to end key consumer protections that have
helped people with pre-existing conditions, including people with
disabilities, access the health care services they need.
The Arc is deeply concerned that the Senate is discussing moving
forward, outside of regular order, without a complete analysis by the
independent Congressional Budget Office (CBO) of the revised bill,
known as the Graham-Cassidy plan. The Arc is also concerned that there
have not been hearings or stakeholder input to assess the bill. Given
the rush to pass the bill before September 30th, CBO will not have time
to do a complete analysis of the bill's impact on people needing health
coverage and Medicaid's long term supports.
Health care consultants and think tanks have tried to fill the CBO gap
by providing analysis that consistently demonstrates the negative
impact on states, including how deep cuts to the Medicaid program would
be over time. For example, a recent study by Avalere showed that for
2020 through 2026, 34 states and DC would see funding cuts. Once the
block grant for Medicaid expansion ends in 2027, all states would see
large cuts (the cut in 2027 alone would be $283 billion). Total cuts to
federal funding for coverage would total over $4 trillion through 2036.
Cuts to the traditional Medicaid program would be more than $1 trillion
over two decades. And looking at the growth rates by population,
federal funding by 2036 would be 15 percent below current law for
people with disabilities, 31 percent below current law for kids, and 37
percent below current law for non-disabled adults. The need won't go
away, so these cuts would be devastating to state Medicaid systems and
mean life and death to people with disabilities.
Nationwide, Medicaid provides essential services to more than 10
million people with disabilities. People with disabilities rely on
Medicaid for personal care services, specialized therapies, intensive
mental health services, special education related services, and other
needed services that are unavailable through private insurance. With
greatly reduced federal contributions to Medicaid as proposed under the
Graham-Cassidy plan, most states would not be able to make up the
difference. Cuts to Medicaid, including to home and community based
services, would force a return to outdated modes of serving people with
disabilities, such as institutional care and segregated services.
Cutting and capping Medicaid will force longer waiting lists for
services in many states. The Arc has worked in a bipartisan manner for
decades at the federal, state, and local level to build a home and
community based system and reduce waiting lists. Waiting lists exist
because the Section 1915 waiver authority allows states to limit
eligibility for services and waive the requirement that all eligible
people in the state receive comparable services. The problems with
waiting lists are not related to the expansion of the Medicaid program
to childless adults. The Medicaid expansion allowed millions of people
with chronic illnesses and disabilities to gain access to health care.
Allegations that the Medicaid expansion are causing waiting lists are
false.
The Arc does not believe, within the radical restructuring of the
Medicaid program and the deep cuts, that any eligible population can be
protected. The Graham-
Cassidy bill includes language exempting children with disabilities
from the per capita cap. If this language is intended to target the 1.2
million children who are eligible for Supplemental Security Income
(SSI), it would leave out many children who have health needs or
disabilities and do not meet SSI's strict income and disability
standards but who become Medicaid eligible through many different
eligibility pathways.
This ``carve out'' implicitly acknowledges that Medicaid under per
capita caps is unacceptable for children with disabilities. These
children grow up to be adults and will face a devastated Medicaid
program. States will not be able to make up the difference from the
deep cuts under per capita caps and will not be able to protect any
group. States will be focused on keeping Medicaid spending under the
cap, or face penalties. The Senate bill's cuts are greater over time
and, to make up for this massive loss of federal funding, states will
be forced to cut services, eligibility groups, reimbursement rates for
providers, make across the board cuts, or take other actions to cut
costs. These cuts will impact the doctors, hospitals, therapists, and
other providers that serve these children. While the traditional match
may be an incentive for some states to continue serving children with
disabilities, there is no specific language in the bill that provides
protections against tightening eligibility for these children or
cutting their services and supports.
The Arc is disappointed that the bill also retains the $19 billion cut
of the enhanced federal match in the Community First Choice Option,
which is a permanent program that provides an enhanced federal match to
any state that chooses the option to provide additional personal
assistance services. Instead, the Senate bill includes a new home and
community based demonstration program. A total of $8 billion is
available over 4 years to a limited number of states. This is a
woefully inadequate response to the deep cuts to Medicaid and the
threat that poses to home and community based services.
In addition, the Graham-Cassidy plan ends the Medicaid expansion and
the current tax credits and cost sharing reductions that assist low
income individuals purchase health insurance in 2020, replacing this
assistance with a block grant that would reduce funding by $239 billion
by 2026. After 2026, there would be no federal funding to help the
millions of Americans, including millions with disabilities, who rely
on Medicaid expansion and marketplace coverage to access health care.
These are people who previously fell through the cracks in our system,
such as individuals with disabilities in a mandatory waiting period
before their Medicare coverage begins and millions of people with a
behavioral health condition who previously had no pathway to steady
coverage. Also, millions of family caregivers who work caring for a
child or older adult with a disability and hundreds of thousands of low
wage direct care workers who serve people with disabilities gained
coverage through the Medicaid expansion. Medicaid expansion helps
stabilize our long-term care support networks by keeping caregivers
healthy and reducing turnover.
Likewise, marketplace coverage ensures that people with disabilities
can buy comprehensive and affordable health care and have equal access
to much needed health care including examinations, therapies to regain
abilities after an illness or injury, and affordable medications. We
have serious concerns about the Graham-Cassidy private market
provisions, including the state waiver authority to eliminate
protections for people with pre-existing conditions (including people
with disabilities), older adults, and people who need access to
essential health benefits. The nondiscrimination provisions and health
insurance reforms, the expanded access to long term supports and
services, and the expanded availability of comprehensive and affordable
health care have helped many more individuals with disabilities live in
the community and be successful in school and the work place. No longer
do individuals with disabilities and their families have to make very
difficult choices about whether to pay their mortgage, declare
bankruptcy, or choose between buying groceries and paying for needed
medications.
The lives and independence of people with disabilities are on the line.
The Arc urges you to oppose the Graham-Cassidy plan to preserve health
care and access to community living provided under Medicaid.
The Arc is the largest national community-based organization advocating
for and serving people with intellectual and developmental disabilities
and their families. We have more than 650 state and local chapters
across the United States. If you have any questions, please contact
Julie Ward, Director of Health Policy (ward@
thearc.org).
______
The Arc Wisconsin
P.O. Box 201
Stoughton, WI 53589
https://arcwi.org/
September 22, 2017
U.S. Senate
Committee on Finance
Dirksen Senate Office Bldg.
Washington, DC 20510-6200
Re: Hearing to consider the Graham-Cassidy-Heller-Johnson Proposal
Dear Chairman Hatch, Ranking Member Wyden, Members of the Committee:
The Arc Wisconsin is urging you to preserve the funding structure for
the Medicaid program and the critical services and supports it provides
to people with intellectual and/or developmental disabilities (I/DD) in
Wisconsin and nationwide. Specifically, people with I/DD in Wisconsin
rely on Medicaid funded programs like Family Care, IRIS, Children's
Long-Term Supports, BadgerCare, occupational, physical, and speech
therapies, autism supports, and more. More than 1 million Wisconsin
residents depend on Medicaid for their health insurance and funding for
essential community based care. Two-thirds of Medicaid funding goes to
support people with disabilities and older adults.
The Arc Wisconsin has 15 local chapters and many of them provide
essential Medicaid services to people with I/DD. We are located in Eau
Claire, La Crosse, Richland Center, Fond du Lac, Monroe County, Green
County, Waupaca County, Washington County, Mineral Point, Lincoln
County, Racine, Dane County, Dodge County and Dunn County. The Arc Fond
du Lac is an example of a chapter that employs more than 50 workers and
receives more than 70% of their operating revenue through the Medicaid
program to provide day and residential services to very vulnerable
people.
Wisconsin currently receives a 60% funding match from the federal
government for all its Medicaid programming which includes flexible
waivers that allow individuals and families with disabilities to get
supports in the community that help them to be healthy, allow them to
live in their own homes and keep them out of institutions. These
community-based waiver programs, serving more than 70,000 older adults
and people with disabilities and nearly 7,000 children with
disabilities in Wisconsin, are considered optional under Medicaid and
are predicted to be at risk for elimination through the per capita caps
proposed in the Graham-Cassidy bill.
Wisconsin has worked hard to eliminate waiting lists for community
services for people with the most significant disabilities. This is
unheard of in most other states. By 2018 no adult with a disability who
qualifies for Family Care and IRIS long-term care will have to wait for
supports in our state. The Wisconsin state budget passed this month
includes new funding to eliminate waiting for children with significant
disabilities, including autism and other developmental disabilities.
Unfortunately, analysts of Graham-Cassidy have predicted that states
will likely respond to per capita cap funding restrictions in Medicaid
by instituting waiting lists for services.
Although early estimates of Graham-Cassidy show Wisconsin may not lose
funding immediately, by 2027 Medicaid per capita cap cuts become
increasingly severe for our state. Wisconsin stands to lose
$2,909,000,000 (or nearly $3 billion) by 2027 and $29 billion by 2036.
Nationwide, Medicaid provides essential services to more than 10
million people with disabilities. The disability community and
bipartisan Congressional leaders have worked together for decades to
ensure that adults and children with disabilities have access to home
and community-based services that allow them to live, work, and receive
an education in the community. People with disabilities rely on
Medicaid for nursing and personal care services, specialized therapies,
intensive mental health services, special education related services,
and other needed services that are unavailable through private
insurance.
On behalf of people with I/DD we ask that you consider the impact of
billions of dollars in Medicaid funding reductions in Wisconsin and all
states. With reduced federal spending, we worry that Wisconsin
taxpayers will not be able to make up the difference to maintain our
system of supports. We fear that Wisconsin will be forced to return to
outdated modes of serving people with disabilities, such as
institutional care and segregated services.
The cutting and capping of the Medicaid program over time affects each
state budget differently. It is clear that the proposal will mean
significantly less federal support for any future efforts to rebalance
spending from institutional services to community spending. It is not
likely that states will be able to address the problems of low
reimbursement rates for providers of home and community based services
or to address the need to provide adequate wages for the direct support
workers who provide these critical community services. Quality of care
will surely suffer.
Thank you for considering the harmful consequences per capita caps
would have on individual with disabilities, children, and families in
Wisconsin. We ask that you vote NO on any legislation that cuts or caps
Medicaid.
Sincerely,
Lisa Pugh
Executive Director
David Boelter, Executive Director Kelli Stein, Executive Director
David Oldenburg, President The Arc of Racine County
The Arc Fond du Lac
Ken Hobbs, President Debra J. Hanzel, President
The Arc-Dane County Richland County Arc
Mary Bakalars, Administrative
Coordinator Marit Waack, Executive Director
The Arc La Crosse The Arc Eau Claire
Margaret Galle, President Julie Briggs, Executive Director
Arc of Southwestern Wisconsin Cindy Rowe, President
The Arc Greater Columbia County
______
Arthritis Foundation
1615 L Street, NW, Suite 320
Washington, DC 20036
On behalf of the 54 million adults and children with arthritis in the
United States, the Arthritis Foundation welcomes the opportunity to
submit a statement for the record as the committee debates the latest
proposal to repeal and replace the Affordable Care Act.
The Arthritis Foundation continues to be opposed to the legislation
advanced by Senators Bill Cassidy and Lindsay Graham and is deeply
concerned about the potential weakening of important patient
protections that are guaranteed under current law. Because of the
waiver language in this bill, states could eliminate essential health
benefits such as prescription drug coverage--which patients with
inflammatory forms of arthritis and other rheumatic illnesses rely on
to manage their disease and live healthy, productive lives. People with
rheumatoid arthritis, for instance, rely on biologic therapies for
their care, and the downstream effects of an incomplete essential
health benefits package would be harmful to appropriate care and
treatment. Although the legislation does not eliminate the current pre-
existing condition ban, it opens the door for states to permit health
insurers to deny coverage associated with some conditions. Alarmingly,
this means insurers could impose premium surcharges based on a
patient's medical history or health status.
We are also concerned about the significant cuts to Medicaid should
this bill become law. Due to an anticipated Congressional Budget Office
score that will be incomplete, senators and all Americans are forced to
turn to independent analyses for information on the impacts to coverage
and cost. Per an analysis released by Avalere Health, for example, the
legislation fundamentally changes the traditional approach to funding
Medicaid and penalizes states that expanded Medicaid in favor of states
that chose not to do so. Thus, federal funding to states would decline
by an estimated $215 billion over the 2020-2026 period, after which a
funding cliff requires the block grants to be reappropriated by
Congress.
Importantly, the haste in which this bill is moving for consideration
by the Senate has halted any bipartisan efforts to stabilize the
insurance markets over the short term or move forward on a 5-year
extension of the Children's Health Insurance Program before the end of
the month. Over the course of the year, the Arthritis Foundation has
continually advocated for patient-centered health reforms guided by six
legislative principles. These principles were developed following
surveys and focus groups of patients with arthritis and have informed
our position on the legislation before the Committee. In August, we
detailed several bipartisan recommendations to strengthen and improve
current law. These policies included:
Stabilizing the insurance marketplace through continued cost-
sharing reduction payments to provide insurers certainty, prevent
significant increases in premiums and ensure sufficient consumer choice
in the marketplace.
Ensuring outreach and engagement programs designed to enroll
individuals in health care plans, both to incentivize healthy
individuals to buy insurance, and to ensure that people with chronic
conditions choose the plans that best suit their needs, thereby
achieving a balanced risk pool.
Providing additional flexibility for health savings accounts
(HSAs) so that individuals with chronic illnesses like arthritis have
enough flexibility with their plan to feel confident their health care
needs are met. The legislation before the Committee includes some
policies in this area, such as increasing the annual contribution limit
to the maximum sum of an annual deductible and out-of-pocket expenses
permitted under an HDHP, or allowing the use of HSA funds to pay for
premiums. Focus groups conducted by the Arthritis Foundation have found
that patients with these plans would find value in these flexibilities,
among other important changes to HDHP/HSA plans.
Addressing the proliferation of specialty tiers and rising
levels of coinsurance through policy solutions that would use a capped
copayment structure rather than coinsurance and permit a patient's
cost-sharing responsibility to be spread evenly over the course of the
plan year.
Patients are the ultimate stakeholders in health care. Advancing a
bill that bypasses the full legislative process and fails to capture
the important voice of the patient community is deeply concerning. As
ever, the Arthritis Foundation stands ready to work with the Committee
to develop meaningful legislation and advance bipartisan solutions to
strengthen our health care system. Please contact Vincent Pacileo,
Director of Federal Affairs, at [email protected] or 202-887-2910,
with questions or for more information.
Sincerely,
Anna Hyde
Vice President, Advocacy and Access
______
Association of Maternal and Child Health Programs
1825 K Street, NW, Suite 250
Washington, DC 20006
Main 202-775-0436
Fax 202-478-5120
http://www.amchp.org/
The Association of Maternal and Child Health Programs (AMCHP) has
serious concerns that provisions included in the Graham-Cassidy-Heller-
Johnson proposal would have a negative impact on maternal and child
health populations. Adding potentially millions of additional Americans
to the ranks of the uninsured would strain an already stretched safety
net, reduce opportunities for prevention and early intervention, and
undermine improvements that are promoting continuity of care for women
of reproductive age and children with special health care needs.
Eliminating the Prevention and Public Health Fund would create an
immediate 12 percent gap in the budget for the Centers for Disease
Control and Prevention (CDC) which would in turn force the CDC to
defund critical state and local public health efforts.
The potential for eliminating the requirement to cover Essential Health
Benefits (EHBs) for services such as clinical preventive services,
mental health, and maternity care is particularly troubling. Assurance
of coverage for these services is critical to increasing the likelihood
that pregnant women receive appropriate medical care and that all
babies have a healthy start to life. Waiving the EHBs would return us
to a situation like prior to 2013 when only nine states required
coverage and only 12 percent of individual market plans included
maternity coverage--this at a time when the U.S. has one of the highest
infant mortality rates among industrialized countries and an increasing
maternal mortality rate. In addition, the bill weakens protections for
individuals with pre-existing conditions by allowing states to waive
the current prohibition against charging higher premiums based on
health status. This is particularly concerning for the maternal and
child health community, as insurers would once again be allowed to
charge women more for having had a prior pregnancy or families more for
having a child born with special health needs.
______
Letter Submitted by Kristine Beck
To: Senate Finance Committee
Re: Testimony submitted for consideration to the hearing to consider
the Graham-Cassidy-Heller-Johnson proposal on September 25, 2017
Dear Senate Finance Committee Members:
I am writing to express my opposition to the Graham-Cassidy-Heller-
Johnson proposal. I am deeply concerned, particularly about the
potential cuts to Medicaid. Medicaid protects tens of millions of our
most vulnerable citizens: the elderly, people with disabilities, and
young children. I serve Wisconsin's Medicaid population, and every day
I see how it provides life-saving care, from dialysis to chemotherapy
to cardiac surgery, and on and on. Cuts and caps will end up depriving
thousands of Wisconsin residents of the care they need to live with
dignity and independence.
Closer to home, I have a niece and a brother-in-law who rely on
Medicaid for their healthcare. It would break my heart to see them
forgoing treatment for kidney disease or cancer because Medicaid was
curtailed.
I am also concerned about the potential end of protections for people
with pre-
existing conditions. That protection has saved lives and has averted
cruel, needless medical bankruptcies. I myself have a pre-existing
condition. If I were unable to receive healthcare for my condition, I
quite possibly could die within a few years. Ending protections for
people with pre-existing conditions is cruel and unnecessary.
Further, I am alarmed about the speed and secrecy with which this
Proposal was developed. Such an important issue, the very lives of our
citizens, warrants an open and deliberate process.
Please slow down and allow the voices of our citizens to be heard and
their needs considered. We deserve at least that much respect.
______
Blue Shield of California
50 Beale Street
San Francisco, CA 94105
U.S. Senate
Committee on Finance
Dirksen Senate Office Bldg.
Washington, DC 20510-6200
Dear Senate Committee on Finance:
Our mission at Blue Shield of California is to ensure that all
Californians have access to high quality health care at an affordable
price. We have consistently maintained that this is the standard
against which we measure all health care policy proposals. We are
therefore writing to express our strong opposition to the Cassidy-
Graham proposal that the Senate may soon consider. We believe this
proposal will cause millions of Californians to lose their health
insurance coverage while requiring major state tax increases over the
long-term to fund basic levels of access. This would undo much of the
substantial progress California has made expanding coverage in recent
years.
The bill from Senator Cassidy and Senator Graham would bring about an
unprecedented cut and redistribution of federal funding. Paradoxically,
because of California's success in reducing the percentage of
uninsured, our state will feel the brunt of the extreme cuts in
spending this bill would mandate.
Independent estimates show that California would see a $78 billion cut
by 2026, when compared to current law.\1\ In contrast, Texas--which has
done little to expand coverage to the uninsured--would receive a $35
billion increase.\2\ In total dollars, California would see nearly $30
billion more in cuts than any other state. As with previous repeal and
replace bills, the result would be that lower-income individuals and
families trying to work their way into the middle class would lose
their insurance coverage. The proposal would also cut off funding
entirely in 2027. While supporters say that this considerable
appropriation will be re-authorized easily, if recent history is a
guide, the need to reauthorize what would be a $2 trillion program will
instead lead to even more political turmoil and uncertainty for those
with coverage and for states seeking to provide health care to their
most vulnerable citizens.
---------------------------------------------------------------------------
\1\ Avalere Analysis of Cassidy-Graham bill, September 20, 2017.
\2\ This is true even though analyses show that California is a
donor state in federal taxes while Texas currently receives more back
from the federal government than it pays. See Dallas Morning News,
``Texas Can No Longer Complain That it Gives More Than It Gets From the
Federal Government,'' August 2012.
In short, none of us need an official CBO score to know that funding
reductions of this magnitude will ultimately lead to millions of
Californians losing coverage. No amount of state flexibility nor
promises of future government action can possibly fill that financial
void. We should all be seeking ways to maintain and expand coverage to
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high quality, sustainably affordable health care.
We continue to believe that bipartisan compromise can result in
improvements to these critical health care programs that will make them
sustainably affordable and fiscally responsible in the long-term, while
preserving coverage for the most vulnerable among us. The recent
Alexander-Murray hearings have shown remarkable agreement among diverse
stakeholders around areas of potential compromise, including funding
the cost sharing reduction benefit, providing more flexibility for
states to innovate within appropriate guardrails, and addressing high-
cost enrollees. We believe Congress should continue to focus on
building from areas of consensus rather than again pursuing a partisan
and divisive path.
We recognize that we still have further to go to guarantee affordable
coverage for all Californians. However, this bill would take us further
away from that goal, and for that reason we strongly oppose it.
Sincerely,
Gary Cohen
Vice President, Government Affairs
______
Blue Cross Blue Shield of Massachusetts (BCBSMA)
September 22, 2017
The Honorable Orrin Hatch The Honorable Ron Wyden
Chairman Ranking Member
Committee on Finance Committee on Finance
U.S. Senate U.S. Senate
219 Dirsken Senate Office Building 219 Dirksen Senate Office Building
Washington, DC 20510 Washington, DC 20510
Dear Chairman Hatch and Ranking Member Wyden:
On behalf of Blue Cross Blue Shield of Massachusetts (``BCBSMA''), I am
writing in opposition to the ``Graham-Cassidy-Heller-Johnson'' proposal
scheduled for a hearing before the Senate Finance Committee. When
considered both in the short and long term, the measure will
destabilize state insurance markets and undermine the ability to
provide quality, affordable coverage and care, regardless of condition.
As a nation, we've reached a historically high insured rate among our
citizens--this bill will jeopardize these meaningful gains in coverage.
At BCBSMA, we are proud of our history as a not-for-profit organization
that was founded 80 years ago by a group of community-minded business
leaders. Our history--and our future--is one of collaborating with the
community to improve the health and quality of care that our members,
and all citizens of the Commonwealth, receive. Providing coverage to
almost 3 million customers, at BCBSMA, our vision is a transformed
health care system that provides safe, timely, effective, affordable,
patient-centered care for all.
Prior to the Affordable Care Act (``ACA'') being passed in 2010, BCBSMA
weighed in extensively with the Senate Finance Committee, as well as
other committees of jurisdiction in the Senate and House of
Representatives. We have continued to do so over the past several years
including input to the Senate Finance Committee this past May. Given
our experience in Massachusetts at reforming the health care system and
Massachusetts' continued success in providing insurance coverage to
over 97% of our residents, we believe we are uniquely qualified to
offer our thoughts and insights on these issues. While not a
comprehensive list of the many challenges of the proposal, our views on
the top three provisions that will both negatively undermine the
markets and directly impact the health of Americans across the nation
are expressed below:
First, instead of stabilizing the individual market in the short-term--
a goal shared by both Republican and Democrat policymakers at the state
and federal levels, as well almost every health care association and
think tank--repeal of the individual mandate will immediately
destabilize the market as products and rates have been approved based
on the assumption that the mandate is in place. Moreover, without the
individual mandate or any policy to encourage younger and healthier
people to enroll and maintain coverage, the risk pool will deteriorate
and drive up costs for those with insurance coverage. Additionally, in
the short-term, the proposal does not provide certainty on cost-sharing
reduction (CSR) payments, continuing the ongoing uncertainty as the
2018 open enrollment period quickly approaches.
Second, federal spending cuts to states are dramatic and severe. These
cuts will create fiscal cliffs for states and will have a profound
impact on the most vulnerable of our residents and neighbors--the
disabled, the elderly, and the working poor. With under 2 years to plan
for the budgetary, programmatic, and enrollment challenges created by
this punitive policy, states and the beneficiaries served by these
programs will face substantial chaos. Importantly, the impact is not
limited to Medicaid; the impact to the individual market will also be
acute.
Notably, while designed to offer states ``flexibility,'' the block
grants proposed by the measure directly penalize states that expanded
their Medicaid program. This approach puts politics over policy at the
expense of those most in need of care. Moreover, the funding formula
also fails to account for broader health care policy trends that are
outside the control of states, such as, but not limited to, growth in
the volume and intensity of services per person, or the aging of the
population.
Finally, the inclusion of a provision that gives states the ability to
waive out of fundamental consumer protections, including the
prohibition on medical underwriting with only a statement of how the
state will ``intend'' to maintain access to ``adequate'' and
``affordable'' coverage is unnecessary and divisive. As our CEO, Andrew
Dreyfus, eloquently noted in an op-ed published by The Hill at the time
that the Senate was considering this issue earlier this summer--
Rather than allowing pre-existing medical conditions to again
divide us, let's acknowledge that illness is actually a great
equalizer. From birth to death, no one is immune from the risks
of disabling injury or chronic illness. It may befall you, your
spouse, your parent, or your child. If it's not your family,
it's your co-worker, your friend, or your neighbor. That's one
of the reasons individuals and families so easily bond with
people facing similar medical challenges, regardless of their
political beliefs or economic background, and it's why tens of
millions of people join together to donate and raise money for
efforts to find cures and support treatment. We're all in it
together.
A return to charging higher premiums for people with pre-
existing conditions reinforces the mistaken notion that serious
illness stems largely from personal choice. Most illness and
disability is due not to choice but to bad luck and bad
circumstances--the accidents of birth and life, including
genes, economic and social factors, workplace conditions, and
exposure to infection and toxins. Even for those illnesses
where personal choice can matter, chance still plays a big
role. Some people manage to avoid serious illness and live long
lives despite unhealthy habits and poor choices, while others
who lead much healthier lifestyles may not be nearly as
fortunate.
A fair, stable health insurance system requires an adequate
number of both sick and healthy people who contribute to the
pool of funds available to pay medical claims. That's not the
case in some of the state marketplaces where individuals can
buy coverage--too few healthy, lower-cost people have enrolled
to balance the higher costs of their sicker population. So it's
perfectly legitimate for Congress to consider better ways to
encourage healthy individuals to buy and maintain insurance and
there are a variety of available mechanisms to achieve this
goal. What Congress must not and need not do, however, is
return us to the days when insurers could increase premiums for
individuals with pre-existing conditions. We should take this
option out of the policy conversation and out of our healthcare
system for good. We should agree that, whether we are healthy
or sick, we are all created equal, and our health insurance
system should reflect this American principle.
Blue Cross Blue Shield of Massachusetts remains committed to working
with Congress toward the goal of ensuring access to affordable, quality
health care for the citizens of Massachusetts and the nation and urge
our elected leaders to continue working in a bipartisan manner to
achieve this outcome.
Very Truly Yours,
Deirdre W. Savage
Vice President
______
Brain Injury Association of America
1608 Spring Hill Road, Suite 110
Vienna, VA 22182
Phone: (703) 761-0750
Fax: (703) 761-0755
https://www.biausa.org/
Chairman Hatch, Ranking Member Wyden, and Members of the Finance
Committee:
The Brain Injury Association of America (BIAA) is the nation's oldest
and largest brain injury advocacy organization leading the fight to
make comprehensive rehabilitation accessible to patients with brain
injury. BIAA thanks Chairman Hatch for his continued sponsorship of the
TBI Act, the only federal legislation addressing the needs of 5.3
million Americans who live with a disability because of TBI.
BIAA is strongly opposed to H.R. 1628, the Graham-Cassidy-Heller-
Johnson proposal. The legislation would seriously undermine health care
coverage in the individual market by allowing states to control
consumer protections, by systematically dismantling the Medicaid
expansion under the Patient Protection and Affordable Care Act (ACA),
and shifting the original Medicaid program to a per capita caps
formula. Taken together, these measures would lead to significantly
less coverage of rehabilitation services and devices.
Traumatic brain injury (TBI) is a misdiagnosed, misunderstood, under-
funded, neurological disease affecting at least 2.5 million children
and adults in the U.S. each year. Depending on type and severity, brain
injuries can lead to physical, cognitive, psychosocial, or behavioral
impairments ranging from balance and coordination problems to loss of
hearing, vision, or speech. Fatigue, memory loss, concentration
difficulty, anxiety, depression, impulsivity, and impaired judgment are
also common after brain injury. Even so-called ``mild'' injuries can
have devastating consequences that require intensive treatment and
long-term care. Often called the ``silent epidemic,'' brain injury
affects people in ways that are invisible. The injury can lower
performance at school and at work, interfere with personal
relationships, and bring financial ruin.
For many people with brain injury, rehabilitation is the single most
effective treatment to restore function and arrest, reverse or mitigate
disease-causative and
disease-accelerative processes subsequent to injury. Rehabilitation is
provided in a variety of settings, depending on the needs of the
individual, including acute care hospitals, inpatient rehabilitation
centers, and nonhospital alternative medical delivery settings, such as
residential/transitional rehabilitation programs and day treatment
programs. Cognitive rehabilitation is a systematically applied set of
medical and therapeutic services designed to improve cognitive
functioning. Cognitive rehabilitation can play a key role in treatment
and management of behavioral, emotional and psychosocial problems
including problems of suicide and substance abuse.
BIAA stresses the importance of maintaining access to rehabilitation
services and devices as an essential health benefit in any repeal and
replacement of ACA that advances in the House and Senate.
The ACA created in statute the Essential Health Benefits (EHB) category
of ``rehabilitative and habilitative services and devices.'' ACA,
Section 1302(b).
Rehabilitation services and devices--Rehabilitative services,
including devices, on the other hand, are provided to help a
person regain, maintain, or prevent deterioration of a skill or
function that has been acquired but then lost or impaired due
to illness, injury, or disabling condition.\1\
---------------------------------------------------------------------------
\1\ http://www.gpo.gov/fdsys/pkg/FR-2015-02-27/pdf/2015-03751.pdf,
at 10811.
For the first time, this definition established a uniform understanding
of the federal meaning of rehabilitation services and devices that
became a standard for national insurance coverage, setting a floor for
plans sold under the ACA exchanges. The definition has been adopted by
states for use in Medicaid expansion programs. BIAA supports the
preservation of the EHB category of ``rehabilitative and habilitative
services and devices'' and the subsequent regulatory definition and
related interpretations duly promulgated, as a standard of coverage for
rehabilitation under any version of ACA replacement legislation. BIAA
believes that adopting the uniform federal definition of rehabilitation
services and devices minimizes the variability in benefits across
states and uncertainty in coverage for children and adults in need of
---------------------------------------------------------------------------
rehabilitation.
Thank you for considering our concerns as you debate this monumental
legislation that will impact the lives of so many. Please contact Amy
Colberg, Director of Government Affairs, [email protected] with any
questions.
______
Letter Submitted by Ruth Hong Brininger
Dear Senate Committee on Finance,
I am the mother of two young boys--3 years and 19 months of age. I am
writing to urge you to NOT pass the Graham-Cassidy-Heller-Johnson
proposal. You cannot allow the states to waive protections that the
Affordable Care Act put into place for those with pre-existing
conditions nor make cuts to the Medicaid program from the federal
budget.
My three year-old was born 5 weeks premature and will continue to need
healthcare services at every stage of life. Ever since, he's needed
care from an adenoid removal to a tonsillectomy. He currently receives
speech therapy through an individualized education plan (IEP) in
preschool. As part of his IEP evaluation while he did not reach the
threshold to receive occupational therapy through the school system, he
receives OT weekly through our local children's hospital to help him
with his gross motor skills. Without coverage, he would not receive the
critical services to be healthy, grow and develop among his peers.
My 19 month old is diagnosed with mild-to-moderate bronchomalacia.
Fifty percent of his airways collapse due to weakened cartilage. He's
had his fair share of procedures and visits to urgent care. He has
daily medication, rescue meds, and an emergency plan due to respiratory
illnesses that exacerbate his bronchomalacia. Luckily, he's able to
receive the critical care he needs because he's protected by the
prohibition of states to waive critical healthcare services to those
with pre-existing conditions.
I couldn't imagine what a family who may not have coverage or those who
rely upon Medicaid would do if their children were subjected to the
health conditions that my children live with every day. I urge you to
vote NO on the Graham-Cassidy-Heller-Johnson proposal.
A concerned constituent,
Ruth Hong Brininger
______
Charles Bruner, Ph.D.
Health Equity and Young Children Initiative
While some of the focus of the Graham-Cassidy bill is related to
provisions specific to the Affordable Care Act and its insurance
mandate, the bill also makes huge and irreparable changes to Medicaid,
which has been a 50-year state-federal partnership in providing health
care to the country's most vulnerable citizens. Graham-Cassidy turns
the Medicaid program over to the states as a block grant, with one-
quarter less funding. For Iowa, the state in which I live, this will be
an estimated reduction in federal support of $525 million in 2026,
alone.
Currently, Medicaid covers 65 percent of all frail seniors who live in
nursing homes. Medicaid covers more than 80 percent of all people with
serious disabilities--physical and mental--that require them to be in
institutional or group care or receive extensive and ongoing home
health services. Medicaid and CHIP (the federal child health insurance
program, known in Iowa as hawk-i) cover half of all children in the
United States, the vast majority in working families, where those
employed in the family do not have access to family health insurance
coverage through their employer or simply cannot afford what is
offered. This, in large measure, is because the average cost of such
family coverage is more than $15,000 per year (which neither employers
nor their employees can afford to pick up, particularly for small and
lower-wage businesses).
Although the Graham-Cassidy bill has not been scored for its impact by
the nonpartisan Congressional Budget Office, that score is expected to
show it will increase the number of uninsured Americans by more than 20
million. Its impacts, however, will be far more than that in the actual
care that will be available--for seniors, persons with disabilities,
and children. Even if states are able to continue some level of
coverage for these groups, the reductions in federal funding will
result in more restrictions, less care, and poorer health.
This is the reason that Graham-Cassidy is opposed by organizations from
A to Z (from AARP to Zero to Three and virtually every other organized
group representing health consumers and health advocates), as well as
medical providers (from primary care practitioners to hospitals and
community health centers).
Even if someone is not himself or herself covered by Medicaid, the
effects of these cuts to Medicaid will have an effect, driving up
health insurance costs, as hospitals and other providers lose revenue
while still being expected to provide emergency services as charity
care (or as bad debt). Virtually everyone knows someone who, because of
a disability or infirmity, depends upon Medicaid for life-preserving
care and will be threatened by this legislation.
If Congress even hinted at cutting Medicare by one-quarter and turning
it over to the states, the outcries would be enormous. Instead, members
of Congress take great pride in Medicare and often campaign on
protecting and improving it.
Today, the outcries are pretty enormous against the Graham-Cassidy
bill. Members of Congress should begin to take equivalent pride in
Medicaid and look at ways to protect and improve, not destroy, it.
That means rejecting the Graham-Cassidy bill and, instead, working to
develop health care policies that can improve health quality and
achieving better health outcomes while encouraging innovations and
reforms that are more cost-effective in achieving those ends.
______
Letter Submitted by Anne Cahill
The Honorable Orrin G. Hatch, Chairman
U.S. Senate Committee on Finance
The Honorable Ron Wyden, Ranking Member
U.S. Senate Committee on Finance
Dear Senator Hatch and Senator Wyden:
As a parent of a daughter with a pre-existing condition, I want to
express my strong opposition to the Graham-Cassidy-Heller-Johnson
healthcare bill. This bill would end the Federal protections for
persons with pre-existing conditions, would allow states to reintroduce
annual and lifetime caps, and allow insurance companies to charge women
more for their coverage. In addition, the essential benefits
established by the Affordable Care Act (ACA) would no longer be
federally mandated. Prior to ACA, 75 percent of the individual
insurance plans did not offer maternity care.
The Graham-Cassidy-Heller-Johnson healthcare bill also ends all cost
sharing payments to low income Americans. My daughter works full time
for a small business and purchases her health insurance through the ACA
marketplace. She currently receives a cost sharing payment that
comprises about 19% of the total cost of her monthly insurance premium.
This is actually a smaller benefit then that she would receive if she
worked for an employer who allowed her to pay for her health insurance
premiums with pre-tax dollars. Why are the ACA cost sharing payments
considered ``bad'' or ``welfare'' but not the tax subsidies being
received by other Americans who pay for premiums with pre-tax dollars?
The nonpartisan experts who have reviewed the Graham-Cassidy-Heller-
Johnson healthcare bill say that it will increase the cost of health
insurance to individuals and tens of millions of Americans will lose
coverage. This is not the direction our country should be moving in.
These healthcare experts include: the Centers for Medicare and Medicaid
Services, the National Association of Medicaid Directors, the
Commonwealth Fund, the Kaiser Family Foundation, the Center on Budget
and Policy Priorities, the Center for American Progress, AARP,
Brookings, Avalere, the American Academy of Actuaries, and the American
Enterprise Institute. In addition, at least two major health insurance
providers, Blue Cross Blue Shield and Kaiser Permanente, the American
Hospital Association and a number of physician associations have
released statements opposing the Graham-Cassidy-Heller-Johnson
healthcare bill.
Finally, I strongly object to how the Graham-Cassidy-Heller-Johnson
healthcare bill is being rushed through with limited discussion, and
little outside input. It is being brought up for a vote before a score
is released by the Congressional Budget Office. Healthcare reform is
too important for it to be treated in this manner. The decisions the
Senate makes on healthcare will not only affect who receives coverage
but will also affect who lives or dies.
My daughter currently can hold down a full time position and is self-
supporting because her illness is kept in remission by the care she
receives. The Graham-
Cassidy-Heller-Johnson healthcare bill would make her care unaffordable
resulting in a relapse of her illness and quite possibly a long painful
death. Please don't tell me that the state high risk care pools for
persons with pre-existing conditions would take care of her. The U.S.
has tried that model and it failed miserably because these pools were
grossly underfunded. The Graham-Cassidy-Heller-Johnson healthcare bill
reduces funding dramatically to most of the states; this does not bode
well for high risk pools.
Please do not pass the Graham-Cassidy-Heller-Johnson healthcare bill.
Sincerely,
Anne Cahill
______
Center for Fiscal Equity
Statement of Michael G. Bindner
Chairman Hatch and Ranking Member Wyden, thank you for the opportunity
to submit these comments for the record to the Committee on Finance.
We write in strong opposition to the bill as presented. It combines the
worst features of the House-passed bill, the bills recently rejected by
the Senate, and the kind of state by state deals designed to add
objecting Senators to the bill's supporters that were so roundly
criticized when health care reform was initially passed. Because the
balance is now so delicate and bipartisanship impossible given recent
remarks by certain members and the Speaker of the House, any hint of
bicameralism is gone, just like when the Affordable Care Act was
passed. The majority has become what it most despised about passing
Obamacare.
The news is not all bad, of course. There is a way to end the high
unearned-income surtax, roll back pre-existing condition reforms and
transform Medicaid so that it is not an onerous future obligation to
the States, but without actually killing lower income Americans or at
least forcing hospitals to care for them in the most expensive manner
and billing them into bankruptcy (which you cannot end because it is in
the Constitution).
This method was initially proposed by President Obama but rejected in
his own party, oddly to pick up conservative Democratic votes in the
Senate (which did not ultimately help their reelections). That method
is a subsidized Public Option. It could include all with pre-existing
conditions or the inability to pay even the most basic insurance (while
ending the ability to write garbage policies that will never pay off).
All other Medicaid for Seniors, the Disabled and those in long-term
care could be federalized in exchange for ending the state and local
tax deduction (SALT) as part of tax reform. Indeed, this whole process
could be married into tax reform in such a way as to help that reform
pass bipartisanly.
We are sure that by now the Committee is well aware of our four-part
tax reform proposal. Only one element applies to subsidizing the public
option and replacing the high unearned income surtaxes, our proposed
Net Business Receipts Tax.
The NBRT is essentially a subtraction VAT with additional tax
expenditures for family support, health care, and the private delivery
of governmental services, to fund entitlement spending and replace
income tax filing for most people (including people who file without
paying), the corporate income tax, business tax filing through
individual income taxes, and the employer contribution to OASI, all
payroll taxes for hospital insurance, disability insurance,
unemployment insurance and survivors under age 60.
Unlike a VAT, an NBRT would not be visible on receipts and should not
be zero rated at the border--nor should it be applied to imports. While
both collect from consumers, the unit of analysis for the NBRT should
be the business rather than the transaction. As such, its application
should be universal--covering both public companies who currently file
business income taxes and private companies who currently file their
business expenses on individual returns.
Employees would all be covered and participants in government funded
remedial education programs would receive coverage and tax credits
through the training providers health plan as if they were employees.
There will be no more separate Medicaid programs for the poor who are
able to learn or work. Those who cannot will be covered by the public
option.
Thank you for the opportunity to address the committee. We are, of
course, available for direct testimony or to answer questions by
members and staff.
______
Children's Hospital Association
600 13th St., NW, Suite 500
Washington, DC 20005
202-753-5500
https://www.childrenshospitals.org/
The Nation's Children's Hospitals Oppose
Graham-Cassidy-Heller-Johnson Bill
The nation's children's hospitals, representing 220 hospitals
nationwide, stand in strong opposition to legislation introduced by
Senators Lindsay Graham, R-SC, Bill Cassidy, R-LA, Dean Heller, R-NV,
and Ron Johnson, R-WI. The bill threatens the health care of over 30
million children who rely on Medicaid and millions more who will be
negatively impacted by changes in consumer protections that guarantee
they receive the pediatric care they require.
The Medicaid provisions in the Graham-Cassidy-Heller-Johnson bill
closely mirror those included in the Better Care Reconciliation Act
(BCRA), legislation already considered and rejected by the Senate.
Under current law, Medicaid guarantees meaningful coverage for eligible
populations, such as low-income children and disabled children, and
flexes up and down based on shifts in the economy and need. By
converting Medicaid to a capped program limiting funding to states, the
bill removes the certainty states count on to provide health care
coverage to the most vulnerable children, including those impacted by
natural disasters and public health emergencies like we are
experiencing today.
Through the Medicaid per capita cap and the new state block grant, the
bill drastically reduces funding for states, especially in the long
term, with a funding cliff beginning in 2027, but does not provide the
mechanisms and support to actually improve care provided to vulnerable
children and their families. The bill is short sighted and will result
in long-term costs and sicker adults when children are unable to access
medically necessary care.
Previous analysis of the impact of the per capita cap model that is the
basis for the Graham-Cassidy-Heller-Johnson bill estimates the cut to
Medicaid for children at more than $40 billion by 2026, and more recent
analyses show a 31 percent decline in Medicaid spending on kids by
2036. Per enrollee, children are already the lowest funded Medicaid
population, and the capped funding provisions risk their financing more
so than adults' given children represent nearly 50 percent of Medicaid
enrollees. This steep decline in our investment in children undermines
their health coverage, benefits and access. It results in severe
economic pressures on states and risks the funding of health care for
all children. We need to invest in our nation's children as the next
generation of leaders, not shortchange their development and potential.
Today, a record 95 percent of children in America have health coverage.
But the Graham-Cassidy-Heller-Johnson health care bill will move us
backwards. Our nation's children certainly deserve more.
This proposal additionally risks further decentralization of the
national pediatric quality information and cross-state referrals so
essential to improved care for our sickest children, including those in
military families. The legislation also weakens important health
services programs for all children, including those covered by private
insurance, with millions of children in working families no longer
assured access to specialized pediatric services regardless of any
underlying medical condition.
On behalf of the millions of children and families we serve, we ask the
Senate Finance Committee to reject the Graham-Cassidy-Heller-Johnson
bill or any bill that cuts Medicaid for children and undermines their
long-term health. The nation's children's hospitals look forward to
working with congressional leaders of both parties to improve Medicaid
for children and families through positive reforms.
______
Consortium for Citizens With Disabilities
1825 K Street, NW, Suite 1200
Washington, DC 20006
Dear Chairman Hatch, Ranking Member Wyden, and members of the Senate
Finance Committee:
Thank you for this opportunity to submit a statement for the record
regarding the September 25, 2017 hearing titled ``Hearing to Consider
the Graham-Cassidy-Heller-Johnson Proposal.''
The Consortium for Citizens with Disabilities (CCD) is the largest
coalition of national organizations working together to advocate for
federal public policy that ensures the self-determination, in
dependence, empowerment, integration and inclusion of children and
adults with disabilities in all aspects of society. The undersigned
members of the Consortium for Citizens with Disabilities (CCD) write to
express strong opposition to the Graham-Cassidy-Heller-Johnson (GCHJ)
proposal.
As we have previously commented on multiple House and Senate proposals,
we cannot overstate the danger facing the millions of adults and
children with disabilities if the proposal's Medicaid provisions are
adopted. The proposal's imposition of a per capita cap and the
elimination of the adult Medicaid expansion would decimate a program
that has provided essential healthcare and long term services and
supports to millions of adults and children with disabilities for
decades. We are also extremely concerned about the changes proposed to
the private individual health insurance market and the tax credits that
currently assist low-income individuals, including individuals with
disabilities, to purchase insurance.
Some 10 million people with disabilities and, often, their families,
depend on the critical services that Medicaid provides for their
health, functioning, independence, and well-being. For decades, the
disability community and bipartisan Congressional leaders have worked
together to ensure that people with disabilities of all ages have
access to home- and community-based services (HCBS) that allow them to
live, work, go to school, and participate in their communities instead
of passing their days in institutions. Medicaid has been a key driver
of innovations in cost-effective community-based care, and is now the
primary program covering HCBS in the United States. Older adults and
people with disabilities rely on Medicaid for nursing and personal care
services, specialized therapies, intensive mental health services,
special education services, and other needed services that are
unavailable through private insurance.
Like other proposals considered by the Senate, the GCHJ bill upends
those critical supports. Per capita caps--which have nothing to do with
the Affordable Care Act--would radically restructure the financing of
the traditional Medicaid program and divorce the federal contribution
from the actual costs of meeting people's health care needs. Caps are
designed solely to cut federal Medicaid support to states, ending a
decades-long state/federal partnership to improve opportunities and
outcomes for our most vulnerable. Slashing federal funds will instigate
state budget crises that stifle the planning and upfront investments
required to create more efficient care systems. Caps will force states
to cut services and eligibility, which will put the lives, health, and
independence of people with disabilities at significant risk. In fact,
because HCBS (including waivers) are optional Medicaid services, they
will likely be among the first targets when states are addressing
budgetary shortfalls. The structure of GCHJ's cap--like the structure
in previous bills--makes cuts worse after it reduces the growth rate in
2025. Independent experts have estimated the Graham-Cassidy per capita
cap alone would cut federal supports to states by $53 billion \1\ $175
billion \2\ by 2026, with steeper cuts increasing to $1.1 trillion \3\
to $3.2 trillion \4\ by 2036.
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\1\ Kaiser Family Foundation, ``State-by-State Estimates of Changes
in Federal Spending on Health Care Under the Graham-Cassidy Bill''
(September 2017), available at http://files.kff.org/attachment/Issue-
Brief-State-by-State-Estimates-of-Changes-in-Federal-Spending-on-
Health-Care-Under-the-Graham-Cassidy-Bill.
\2\ Center on Budget and Policy Priorities, ``Like Other ACA Repeal
Bills, Cassidy-Graham Would Cap and Deeply Cut Medicaid'' (September
21, 2017), available at https://www.cbpp.org/research/health/like-
other-aca-repeal-bills-cassidy-graham-would-cap-and-deeply-cut-
medicaid#.
\3\ Id.
\4\ AARP, ``Sounding the Alarm: The New Senate Health Care Bill
Could Cut $3.2 Trillion From Medicaid by 2036'' (September 19, 2017),
available at http://blog.aarp.org/2017/09/19/sounding-the-alarm-the-
new-senate-health-care-bill-could-cut-3-2-trillion-from-medicaid-by-
2036/.
Limited carve outs and targeted funding pots included in GCHJ pale in
comparison to the scope of these cuts. For example, GCHJ offers a 4-
year $8 billion dollar demonstration to expand Medicaid home and
community-based services--which is not even half of the $19 billion cut
to the Community First Choice option that eight states have implemented
to expand access to necessary in-home services for people with
disabilities.\5\ All individuals on Medicaid will be impacted by cuts
of this magnitude, despite any limited, temporary demonstration funding
or restricted funding carve out for a fraction of the children with
disabilities that Medicaid supports. Throwing billions in extra
temporary funds cannot curb the inevitable, long-term loss of critical
Medicaid services that people with disabilities will face as a result
of per capita caps.
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\5\ Congressional Budget Office, ``Cost Estimate for HR. 1628,'' 33
(June 26, 2017).
In addition, GCHJ ends the Medicaid Expansion and the current tax
credits and cost sharing reductions that assist low income individuals
purchase health insurance in 2020. It replaces this assistance with a
block grant that would reduce federal funding by $239 billion by
2026.\6\ After 2026, Graham-Cassidy cuts off federal funding for people
who today rely on Medicaid expansion and Marketplace coverage,
including millions with disabilities. These are people who previously
fell through the cracks in our system, such as individuals with
disabilities in a mandatory waiting period before their Medicare
coverage begins and millions of people with a behavioral health
condition who previously had no pathway to steady coverage. Also,
millions of family caregivers and hundreds of thousands of low-wage
direct care workers who serve older adults and people with disabilities
gained coverage through the Medicaid expansion. Medicaid expansion
helps stabilize our long-term care support networks by keeping
caregivers healthy and reducing turnover, but would end under Graham-
Cassidy.
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\6\ The Commonwealth Fund, ``Graham-Cassidy: Radical Change in the
Federal-State Health Relationship'' (September 22, 2017), available at
http://www.commonwealthfund.org/publications/blog/2017/sep/graham-
cassidy-and-the-states.
Likewise, Marketplace coverage ensures that people with disabilities
can buy comprehensive and affordable health care and have equal access
to much needed health care including examinations, therapies to regain
abilities after an illness or injury, and affordable medications. We
have serious concerns about GCHJ private market provisions, including
the state waiver authority to eliminate protections for people with
preexisting conditions (including people with disabilities), older
adults, and people who need access to essential health benefits. The
nondiscrimination provisions and health insurance reforms, the expanded
access to long term supports and services, and the expanded
availability of comprehensive and affordable health care have helped
many more individuals with disabilities live in the community and be
successful in school and the work place. No longer do individuals with
disabilities and their families have to make very difficult choices
about whether to pay their mortgage, declare bankruptcy, or choose
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between buying groceries and paying for needed medications.
In short, GCHJ makes health insurance less affordable for millions of
people, particularly people with disabilities, older adults, and those
with chronic health conditions. The cumulative effect of the private
insurance and Medicaid proposals will leave people with disabilities
without care and without choices, caught between Medicaid cuts,
unaffordable private insurance, and limited high risk pools. Based on
prior Congressional Budget Office scores, the Brookings Institute
estimates GCHJ would lead to 15 million fewer individuals having health
insurance from 2018-2019, 21 million fewer individuals from 2020-2026,
and 32 million fewer individuals from 2027 onwards.\7\
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\7\ The Brookings Institute, ``How Will the Graham-Cassidy Proposal
Affect the Number of People With Health Insurance Coverage?''
(September 22, 2017), available at http://www.
brookings.edu/research/how-will-the-graham-cassidy-proposal-affect-the-
number-of-people-with-health-insurance-coverage/.
Finally, we are extremely disappointed that the proposal has not been
considered under regular order and in fact threatens to usurp an active
bipartisan effort to bolster Marketplace coverage. The Senate has a
longstanding history of deliberating policy proposals through
transparent processes, including public hearings, open comment periods
on discussion drafts, and multi-stakeholder meetings. We are
particularly concerned that Senators are expressing support of this
proposal without a Congressional Budget Office (CBO) score that
thoroughly examines the short and long term financial and coverage
impacts. The complete restructuring proposed for the individual private
insurance market is likely to have repercussions on coverage that prior
CBO estimates do not take into account. The Senate Health Education
Labor and Pensions Committee has begun a bipartisan process examining
how to strengthen the Affordable Care Act. We ask all Senators to
reject this proposal and instead engage in the process of regular order
and work toward bipartisan solutions that ensure that all adults and
---------------------------------------------------------------------------
children with disabilities have access to the healthcare they need.
Sincerely,
ACCSES
Advance CLASS/Allies for Independence
American Association of People with Disabilities
American Association on Health and Disability
American Association on Intellectual and Developmental Disabilities
American Civil Liberties Union
American Congress of Rehabilitation Medicine
American Dance Therapy Association
American Foundation for the Blind
American Music Therapy Association
American Network of Community Options and Resources
American Occupational Therapy Association
American Psychological Association
American Therapeutic Recreation Association
Association of Assistive Technology Act Programs
Association of People Supporting Employment First
Association of University Centers on Disabilities
Autism Society
Autism Speaks
Autistic Self Advocacy Network
Bazelon Center for Mental Health Law
Brain Injury Association of America
Center for Public Representation
Children and Adults with Attention-Deficit Hyperactivity Disorder
Christopher and Dana Reeve Foundation
Community Legal Services of Philadelphia
Conference of Educational Administrators of Schools and Programs for
the Deaf
Council for Exceptional Children
Council of Administrators of Special Education
Disability Rights Education and Defense Fund
Division for Early Childhood of the Council for Exceptional Children
Easterseals
Epilepsy Foundation
Family Voices
Higher Education Consortium for Special Education
Institute for Educational Leadership
Jewish Federations of North America
Justice in Aging
Learning Disabilities Association of America
Lupus Foundation of America
Lutheran Services in America Disability Network
Mental Health America
National Academy of Elder Law Attorneys
National Alliance on Mental Illness
National Association for the Advancement of Orthotics and Prosthetics
National Association of Councils on Developmental Disabilities
National Association of School Psychologists
National Association of State Directors of Developmental Disabilities
Services
National Association of State Directors of Special Education
National Association of State Head Injury Administrators
National Center for Learning Disabilities
National Committee to Preserve Social Security and Medicare
National Council for Behavioral Health
National Council on Aging
National Council on Independent Living
National Disability Institute
National Disability Rights Network
National Down Syndrome Congress
National Down Syndrome Society
National Health Law Program
National Multiple Sclerosis Society
National Organization of Social Security Claimants' Representatives
National Respite Coalition
Paralyzed Veterans of America
Parent to Parent USA
School Social Work Association of America
SourceAmerica
Special Needs Alliance
TASH
Teacher Education Division of the Council for Exceptional Children
The Advocacy Institute
The Arc of the United States
The Michael J. Fox Foundation for Parkinson's Research
United Cerebral Palsy
United Spinal Association
______
Letter Submitted by Arlene J. Crawford
U.S. Senate
Committee on Finance
Dirksen Senate Office Bldg.
Washington, DC 20510-6200
Re: Hearing to consider Graham-Cassidy-Heller-Johnson proposal,
Monday, September 25, 2017
Senator Hatch and members of the Senate Finance Committee:
I am writing to share my views on the above-mentioned bill. I strongly
oppose this legislation. I not only oppose the contents, I oppose the
backhanded and unethical way it has been crafted and advanced.
Treating the lives and health of American citizens as some sort of
political football is repulsive. Valuing slogans and political points
above careful and considered governance is a shameful and willful
failure to fulfill jobs you were elected to do.
I have been an independent voter without party affiliation since I
started voting during the Reagan era. Through all those years, I have
been open to candidates of either party, and have voted for both
Republicans and Democrats.
The Republican Party is destroying any claim they have to being a
respectable option by pushing a hastily-written, unscored, undebated
bill through Congress in a blatantly partisan way. You have had
literally years to prepare legislation to tackle the problems the U.S.
has with the healthcare sector, and you wasted them. You don't get
credit for throwing together a half-assed Hail Mary pass now.
Patriotic catchphrases about how states are so amazingly innovative
don't matter--treating healthcare and insurance as the life-altering
topics they are for most Americans does. Write a bipartisan bill, hold
hearings, gather input, accept and debate amendments, get a CBO score.
If the GOP continues to try to run the country like their personal
fiefdom, I will never again vote for anyone with an (R) after their
name on the ballot for local dog catcher, much less any higher office.
Sincerely,
Arlene J. Crawford
______
Cystic Fibrosis Foundation
4550 Montgomery Avenue, Suite 1100 N
Bethesda, MD 20814
Statement Submitted by Preston W. Campbell, III, M.D.,
President and Chief Executive Officer
Dear Chairman Hatch and Ranking Member Wyden:
We are gravely concerned about the bill under discussion today, known
as the Graham, Cassidy, Heller, Johnson proposal (Graham/Cassidy).
Specifically, this bill:
Does not protect patients with pre-existing conditions.
Devastates the Medicaid safety-net.
Opens the door to annual and lifetime coverage caps.
Repeals the guarantee of essential health benefits.
Could result in states bringing back high risk pools.
Such policies would be devastating for people with cystic fibrosis (CF)
and hamper their ability to access adequate, affordable health
insurance.
Please bear in mind the needs of people with CF as you consider this
proposal. The stakes are incredibly high for our community, which
relies on access to vital health care services to maintain health and
well being. It is imperative that any policy changes move us closer to
a system that improves care for everyone, including those who need it
most.
Our Principles
We believe the health insurance market should meet the following
standards, in order to protect the lives and well-being of people with
cystic fibrosis:
Adequacy: Adequate health insurance covers therapies and care
delivered by an accredited care team using the latest research,
clinical guidelines, and best practices.
Affordability: Affordable health plans help ensure access to
needed care in a timely manner from an experienced provider without
undue financial burden.
Availability: Available health coverage provides adequate
benefits at an affordable cost regardless of an individual's income,
employment, health status or geographic location.
People with cystic fibrosis are living longer, healthier lives than
ever before. But these gains in health and longevity depend on people
with CF receiving uninterrupted, multidisciplinary care at an
accredited CF care center--and that requires adequate, affordable
health insurance to be available for patients. For those with cystic
fibrosis, health care coverage is a necessity, not a luxury, and
interruptions in coverage can lead to lapses in care, irreversible lung
damage, and costly hospitalizations.
Graham/Cassidy Does Not Protect Patients With Pre-existing Conditions
Protections in current law guarantee that people with cystic fibrosis
and other diseases cannot be denied health insurance, charged higher
premiums, or denied coverage of specific services because of their
health. All three of these policies are absolutely essential for people
with CF--no single policy is sufficient on its own.
Unfortunately, the Graham/Cassidy proposal would undo these critical
protections in current law by letting insurers charge higher premiums
to those with pre-existing conditions if a state chooses to waive that
protection. This could easily put coverage financially out of reach for
people with cystic fibrosis who purchase coverage in the individual
market, jeopardizing their access to lifesaving treatments that allow
them to maintain their health. Such a proposal also undermines other
protections for people with pre-existing conditions that would remain
in law, as a guarantee of coverage is utterly useless if that coverage
is unaffordable.
Graham/Cassidy Devastates the Medicaid Safety-Net
Medicaid is a crucial source of coverage for patients with serious and
chronic health care needs, including over 50 percent of children and
one-third of adults living with cystic fibrosis.\1\ For many
individuals with CF, Medicaid serves as a payer of last resort by
filling important gaps in coverage left by private health plans. For
instance, Medicaid helps people living with the disease to afford the
increasingly costly co-pays and co-insurance rates for prescription
medications and inpatient and outpatient care. People with CF are
eligible for Medicaid through various pathways, including through
income-related and disability criteria.
---------------------------------------------------------------------------
\1\ Cystic Fibrosis Foundation Patient Registry. 2015 Annual Data
Report. (Online). 2016. Available at: https://www.cff.org/Our-Research/
CF-Patient-Registry/2015-Patient-Registry-Annual-
Data-Report.pdf.
The proposal to convert federal financing of Medicaid to a per capita
cap system is deeply troubling, as this policy would reduce federal
funding for Medicaid by hundreds of billions of dollars.\2\ There is no
magic bullet that will somehow allow states to provide the same level
of services to the same populations with less money. This proposal will
force states to either make up the difference with their own funds--a
seemingly insurmountable hurdle in many states--or cut their programs
by reducing the number of people they serve and the benefits they
provide.
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\2\ Congressional Budget Office. Re: H.R. 1628, the Better Care
Reconciliation Act: An Amendment in the Nature of a Substitute
(ERN17500), as posted on the website of the Senate Committee on the
Budget on July 20, 2017. (Online). July 2017. Available at: https://
www.cbo.gov/system/files/115th-congress-2017-2018/costestimate/52941-
hr1628bcra.pdf. The proposal to convert Medicaid financing to a per
capita cap system in Graham/Cassidy is identical to the proposal in
this bill.
For patients with CF, this means that Medicaid may no longer cover the
care and treatments they need, including breakthrough therapies and
technology. This could be devastating for people with CF who face a
pipeline of promising new treatments that could help them live longer,
healthier lives than ever before. The CF community already experiences
instances in which Medicaid programs deny patients, oftentimes
children, the critical therapies they need because of budget
constraints. A per capita cap will only exacerbate the downward
pressure on Medicaid budgets and will further reduce access to these
---------------------------------------------------------------------------
therapies for patients.
Preserving Medicaid expansion is equally vital. Nearly half of adults
covered by the Medicaid expansion are permanently disabled, have
serious physical or mental conditions, or are in fair or poor
health.\3\ The Graham/Cassidy proposal would remove the option for
Medicaid expansion in states that did not expand and eliminate
expansion programs in states that already chose to expand--an even more
drastic proposal than earlier health care bills in the Senate. This
would result in millions of patients losing vital coverage they depend
upon to maintain their health.
---------------------------------------------------------------------------
\3\ Brantley, Erin, et al. ``Myths About the Medicaid Expansion and
the `Able-Bodied'.'' Health Affairs blog. (Online) March 2017.
Available at: http://healthaffairs.org/blog/2017/03/06/myths-about-the-
medicaid-expansion-and-the-able-bodied/.
---------------------------------------------------------------------------
Graham/Cassidy Opens the Door to Annual and Lifetime Coverage Caps
The current prohibition on annual and lifetime benefit caps is critical
to ensuring access to health care for people with CF. Health care costs
can accumulate very quickly for people with CF, making it easy to reach
such coverage caps. For instance, a father of two daughters with CF
reported that together his children hit over $1 million a year in
medical expenses. The result of such caps can be devastating--leaving
people with CF stranded without any health care coverage.
Unfortunately, by explicitly allowing states to amend essential health
benefit (EHB) standards, Graham/Cassidy creates a back door for
insurers to reinstate annual or lifetime coverage caps. In its analysis
of earlier Senate bills that would have made it easier for states to
change EHB standards, the Congressional Budget Office noted that the
prohibition on annual and lifetime limits only applies to essential
health benefits and changes to this standard could expose patients to
large increases in out-of-pocket spending.\4\ Services included in the
current EHB definition are critical for people with CF, including
prescription drugs, hospitalization, and mental health care. If a state
deemed any of these services ``non-essential'' and insurers imposed
coverage caps on these benefits, people with CF could quickly find
themselves unable to access this vital care.
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\4\ Congressional Budget Office. H.R. 1628, American Health Care
Act of 2017. (Online). May 2017. Available at: https://www.cbo.gov/
system/files/115th-congress-2017-2018/costestimate/hr1628aspassed.pdf.
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Graham/Cassidy Repeals the Guarantee of Essential Health Benefits
Moreover, in addition to opening the door to annual and lifetime
coverage caps, eliminating the guarantee of essential health benefit
coverage for exchange plans would segment the market into plans for
sick people and plans for healthy people. As described above, people
with CF need adequate health insurance that covers the specialized,
multi-disciplinary care they need to maintain their health.
Removing the guarantee of essential health benefits as a coverage floor
would result in insurers selling skimpier plans alongside traditional
health care plans. People with CF and others with chronic diseases
would be more likely to purchase traditional plans, while healthier
individuals would be more likely to purchase the skimpier plans. This
will drive up the cost of plans needed by people with CF and
potentially make coverage unaffordable.
Graham/Cassidy Could Result in States Bringing Back High-Risk Pools
Due to the broad scope of the market-based health care grants, Graham/
Cassidy allows states to use the block grants to establish high-risk
pools. High-risk pools, which put people with serious health conditions
into a separate insurance market, do not work for people with CF and
other chronic diseases and are not an acceptable form of coverage.
Prior experience with high-risk pools demonstrates that the coverage
was unaffordable due to high premiums, usually 150-200 percent of the
average non-group rate.\5\ High-risk pools also often had waiting
periods of up to 12 months, leaving patients struggling to access
critical services while they were waiting for coverage. Finally,
funding constraints resulted in strict enrollment caps and lifetime
coverage limits in many states, causing some individuals to go without
needed coverage either because they could not enroll or they hit their
lifetime cap.\6\
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\5\ National Association of State Comprehensive Health Insurance
Plans. Comprehensive Health Insurance for High-Risk Individuals. 2011.
Available at: http://naschip.org/2011/Quick%20
Checks/25/Premium%20Rate%20Setting%20Methodology%2010.pdf.
\6\ Schwartz, Tanya. ``State High-Risk Pools: An Overview.'' Kaiser
Commission on Medicaid and the Uninsured. January 2010. Available at:
https://kaiserfamilyfoundation.files.wordpress.
com/2013/01/8041.pdf.
Thank you for your consideration. We stand ready to work with members
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of the Senate Finance Committee as they consider this proposal.
______
Disability Rights California (DRC)
LEGAL ADVOCACY UNIT
1330 Broadway, Suite 500
Oakland, CA 94612
Tel: (510) 267-1200
TTY: (800) 719-5798
Intake Line: (800) 776-5746
Fax: (510) 267-1201
https://www.disabilityrightsca.org/
Dear Chairman Hatch, Ranking Member Wyden, and Honorable Senate Finance
Committee Members:
We write to urge you to reject the Graham-Cassidy-Heller-Johnson bill,
which will have devastating effects on Californians with disabilities.
Disability Rights California (DRC) is the protection and advocacy
agency for California, established to protect, advocate for and advance
the human, legal and service rights of Californians with disabilities.
Since 1978, Disability Rights California has provided essential legal
services to people with disabilities. In the last year, Disability
Rights California provided legal assistance to nearly 26,000
Californians with disabilities. A significant focus of our work is
ensuring access to critical health and long-term services and supports.
Here is one example of our work.
Mrs. Jones called DRC because her husband had become disabled from a
stroke. She had depleted her savings paying for home care and was on
the verge of declaring bankruptcy. Mr. Jones' retirement pension was
not enough to pay for all of his care needs. DRC assisted Mrs. Jones to
apply for Medi-Cal (California's Medicaid program) for her husband, who
became eligible under the ``spousal impoverishment'' provision of the
Affordable Care Act. By receiving Medi-Cal, Mrs. Jones can hire
attendants to help Care for her husband at home, instead of placing him
in a nursing home, which would be more costly and result in a
devastating separation from his home and family.
The Graham-Cassidy-Heller-Johnson proposal, which would repeal the
Affordable Care Act (ACA) and fundamentally change Medicaid, will be
catastrophic for Californians with disabilities. If this bill passes,
states will no longer be required to offer essential health benefits
such as mental health and substance abuse treatment; it will undermine
and eliminate protections for people with pre-existing conditions; the
subsidies for health insurance exchanges will end; and cost sharing
reduction for low income individuals will be eliminated. The bill will
also decimate the Medicaid program, ending more than 50 years of a
federal-state partnership ensuring health care coverage for low-income
and disabled Americans. Instead, California's Medicaid program would
face enormous cuts through block grants and per capita cuts, and the
ACA's Medicaid expansion would end. In California, 14.1 million people,
including children and adults with disabilities and seniors, receive
their health care services through Medi-Cal (California's Medicaid
program). Almost 4 million people gained coverage through the ACA
expansion of Medi-Cal. The health and economic consequences of this
proposal for individuals with disabilities and our state will be
devastating.
The Graham-Cassidy bill proposes to redistribute federal resources from
large populous states (who took advantage of the ACA in order to serve
their residents and ensure coverage to as many needy people as
possible) and will result in California losing $28 billion dollars
through 2026, then jumping to $57.5 billion in 2027.\1\ The California
Department of Health Care Services' analysis concluded: ``Simply
stated, this proposal is the most devastating of the three federal
health care proposals that we have evaluated this year.'' \2\
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\1\ http://laborcenter.berkeley.edu/the-gops-last-ditch-effort-to-
repeal-the-affordable-care-act-is-the-worst one-yet-for-california/.
\2\ http://www.dhcs.ca.gov/Documents/
Graham_Cassidy_Impact_Memo_DHCS_092217.pdf at 1.
The Congressional Budget Office estimates Medicaid would be cut by over
a quarter (26%) by 2026 and over a third (35%) by 2036. The per capita
caps proposal would shift the responsibility for 100% of the costs
above the per-beneficiary cap back to the state. It would also not
account or adjust for increasing health care costs, an aging
---------------------------------------------------------------------------
population, or public health emergencies.
In addition, Graham-Cassidy directly threatens the 2.3 million people
who buy coverage in the individual market, in which 1.5 million are in
Covered California (1.2 million who get ACA tax subsidies.)
California will lose a total cumulative cut of $114.6 billion between
2020 and 2027, and another $5-6 million annually in subsidies now
available through Covered California.\3\ In total, 6.7 million
Californians would lose coverage in 2027; this will disproportionately
hurt those in areas of the state with the highest Medi-Cal enrollment,
including the Central Valley, Imperial Valley, and parts of Los
Angeles.\4\
---------------------------------------------------------------------------
\3\ http://laborcenter.berkeley.edu/the-gops-last-ditch-effort-to-
repeal-the-affordable-care-act-is-the-worst-one-yet-for-california/.
\4\ http://laborcenter.berkeley.edu/the-gops-last-ditch-effort-to-
repeal-the-affordable-care-act-is-the-worst-one-yet-for-california/.
This proposal will be even more detrimental to people with disabilities
and California's economy than earlier health care proposals. Medi-Cal
is the primary funder of critical home- and community-based services
(HCBS), ensuring that people with disabilities both young and old can
receive services that allow them to live in their own homes, go to
---------------------------------------------------------------------------
school, work, and participate in their communities.
These HCBS services are optional under Medicaid and states could
eliminate them under the Graham-Cassidy bill. Because private insurance
largely does not cover the nursing and personal care services,
specialized therapies, intensive mental health services, special
education services, and other needed services, people with disabilities
must rely on Medicaid HCBS services. For example, according to the
California Department of Health Care Services:
California's [In-Home Supportive Services attendant care]
program is the largest in the country, and is the core of our
home- and community-based system that allows the elderly and
disabled to remain in their homes rather than be placed in a
more costly institutional care setting. \5\
---------------------------------------------------------------------------
\5\ http://www.dhcs.ca.gov/Documents/
Graham_Cassidy_Impact_Memo_DHCS_092217.pdf at 4.
These services are now in imminent danger. Cuts to critical and cost-
effective Medicaid HCBS services like IHSS will result in waitlists,
and will force people into more expensive institutions, resulting in
the unnecessary movement of people away from their families and home
---------------------------------------------------------------------------
communities.
We urge you to protect Californians with disabilities and reject this
proposal, as well as any other attempt to gut the fundamental and life-
saving benefits provided to millions through Medicaid and the ACA.
Sincerely,
Catherine Blakemore
Executive Director
______
Disability Rights Ohio (DRO)
50 W. Broad Street, Suite 1400
Columbus, Ohio 43215-5923
614-466-7264 or 800-282-9181
FAX 614-644-1888
TTY 614-728-2553 or 800-858-3542
http://www.disabilityrightsohio.org/
Chairman Hatch, Ranking Member Wyden, and members of the United States
Senate Committee on Finance, thank you for the opportunity to provide
written testimony in opposition to the Graham-Cassidy-Heller-Johnson
(``GCHJ'') health care proposal. Disability Rights Ohio (``DRO'') urges
the members of the committee NOT to support this bill. If enacted, this
legislation would be devastating to the over 3 million people in Ohio
served by Medicaid including people with disabilities. Medicaid
provides these individuals the opportunity to live and work in their
communities; any cuts, like those proposed in GCHJ, have the potential
to force people with disabilities back into institutionalized settings.
Moreover, expansion of Medicaid has allowed approximately 700,000
Ohioans, many of them with disabilities, to receive health care. This
has allowed Ohio to provide treatment for individuals caught in the
opioid epidemic, who frequently experience co-morbidity with mental and
physical illness, and who were not receiving medical care prior to the
expansion.
BACKGROUND
_______________________________________________________________________
Disability Rights Ohio is a non-profit corporation registered in the
state of Ohio. It is designated by Ohio's Governor under the
Developmental Disabilities Act and other federal laws as the system to
protect and advocate for the rights of people with disabilities in
Ohio. DRO's mission is to advocate for the human, civil, and legal
rights of people with disabilities in Ohio. We have broad experience
providing legal and policy advocacy for our clients and their families,
and as a result DRO has a unique perspective on the importance of
adequate health care and in particular, Medicaid for Ohioans with
disabilities.
This is true in the general sense, as our clients often rely on
Medicaid for health insurance. But this also can assist the individual
to become more independent and a productive member of society through
programs like Medicaid Buy-in, which allows people with disabilities to
gain employment without losing necessary health care that may not be
provided by an employer. The health care exchanges have also provided a
meaningful opportunity for people with disabilities to gain health
insurance without regard to pre-existing conditions (i.e., their
disability).
In addition, the large majority of long term services and supports
(LTSS) for elders and people with disabilities in Ohio are paid for
through Medicaid. While the state has a way to go, Ohio has been making
progress in rebalancing its LTSS away from institutions and into home
and community based services. The Americans with Disabilities Act of
1990 (``ADA'') requires equal opportunity and access for people with
disabilities, and undue segregation in an institutional placement is
discrimination under the ADA. The state's programs must be designed to
promote integration into the community. HCBS Waivers are the main
driver of this change, and in Ohio cuts to Medicaid will, with
certainty, limit progress in this area and reduce the effectiveness of
Ohio's efforts, and force people with disabilities back into
institutionalized settings.
This testimony will be divided into two sections. First, it will
demonstrate the importance of Medicaid in the lives of people with
disabilities in Ohio by sharing two reports DRO published showing how
Medicaid helps individuals become fully integrated into their
communities. Second it will focus on the major concerns with the GCHJ
proposal and the devastating impact it would have on people with
disabilities.
MEDICAID MATTERS
_______________________________________________________________________
Medicaid is intrinsically important for the over 38,000 people with
disabilities in Ohio who are served through Medicaid waivers. These
waivers allow people with disabilities the ability to live and work in
their communities. Because of this, DRO published two (2) reports that
detail how Medicaid helps people with disabilities in Ohio: Medicaid
Matters \1\ and Medicaid Myths.\2\
---------------------------------------------------------------------------
\1\ The full publication can be viewed on our website at: http://
www.disabilityrightsohio.org/assets/documents/
dro_justin_martin_medicaid_booklet.pdf.
\2\ The full publication can be viewed on our website at: http://
www.disabilityrightsohio.org/assets/documents/
dro_medicaidmyths_2017.pdf.
DRO's Medicaid Myths publication shows the various ways that Medicaid
provides services to people with disabilities and allows them the
opportunity to live and work in their communities. One way is through
HCBS waivers that provide service and supports to people with
disabilities in their home. This essential service allows for
individuals to remain in their homes and be fully integrated into their
communities, while diverting them from being placed unnecessarily in
institutional settings. Another way is through essential in-school
services to children with disabilities. These services help children to
learn alongside their peers in traditional school environments,
supporting the requirement in federal law of full inclusion of children
---------------------------------------------------------------------------
with disabilities in their schools.
DRO's Medicaid Matters details the incredible story of Justin Martin.
He attends Kenyon College with plans to become an inspiring teacher.
Justin's HCBS waiver allows him the ability to go to college alongside
his peers and receive the necessary supports he needs to be successful.
This would not be attainable without Medicaid. With the waiver, Justin
will graduate and obtain a job in the community and contribute like any
other adult his age. Cuts to Medicaid would stop countless other people
with disabilities like Justin from obtaining this same kind of success.
To retain the success of Medicaid in helping people with disabilities
live and work in their communities, as shared in the DRO publications,
members of the United States Senate Committee on Finance should NOT
support the GCHJ proposal, which would weaken the Medicaid program and
prevent people with disabilities from being fully integrated in their
communities.
NEGATIVE IMPLICATIONS
_______________________________________________________________________
The GCHJ proposal has multiple provisions that would drastically impact
the lives of people with disabilities. Ohio has an obligation under
Olmstead to provide services to people with disabilities in community-
based settings. GCHJ makes drastic cuts and changes to the Medicaid
program that would create devastating impacts on the lives of people
with disabilities who live and work in their communities. The following
is a list of provisions in the GCHJ proposal that are concerning and
problematic for people with disabilities in Ohio.
Implementing per capita caps. Per capita caps would inhibit Ohio's
ability to pay for rising costs in services like accommodations to help
individuals in and out of the shower in the home, wheelchair ramps, and
personal care aides, all of which are needed to allow for individuals
to live at home and work in their communities. HCBS waivers are not
required services and per capita caps will force Ohio to make drastic
cuts, preventing people with disabilities to live and work in their
communities. Cuts to essential in-home care services puts individuals
who need LTSS at risk of institutionalization.
Ohio already has as many as 40,000 individuals on waitlists for home
and community-based services. Even those who meet the requirements to
receive a waiver can be put on a waitlist if there is not an open
``slot.'' Cuts to Medicaid ensure that more people will be waiting for
essential benefits that are necessary for them live and work in their
communities.
Eliminating coverage for those with mental illness. GCHJ eliminates
Medicaid expansion in 2020 and with it ends coverage for the over
700,000 people who are served in Ohio through the program, including
those who have mental illness and are receiving services in home and
community-based settings. Currently, Ohio receives a 90% matching rate
for Medicaid expansion enrollees, the GCHJ proposal would end this
matching rate in 2020 and states would be required to pay for 100% of
these services. With an already limited state budget, Ohio would be
forced to make severe cuts to this program, if not eliminate it.
The GCHJ threatens the ability of people with disabilities to receive
basic health care, including mental health and addiction services;
sustain employment; and to live in their communities. Progress has been
made to fully integrated people with disabilities and states are
obligated to continue this work. Cuts to Medicaid will severely hamper
further progress.
CONCLUSION
_______________________________________________________________________
DRO understands the current health care system can be improved, but
block grants and cuts are not the answer. There is already a bipartisan
effort being made in the Senate to address the real concerns with our
health care system. By focusing efforts on this process and away from
undue and unnecessary cuts to Medicaid, effective reforms can be made.
DRO hopes the stories we have shared provide insight as to how
important Medicaid is to the lives of people with disabilities. GCHJ
would be extremely detrimental to the lives of people with disabilities
in Ohio. We urge members of the committee to oppose GCHJ.
Thank you for allowing DRO the opportunity to provide testimony on the
GCHJ proposal. If you have any questions or want to discuss this matter
further, please contact me at your convenience.
______
Disability Rights Wisconsin (DRW)
131 W. Wilson Street, Suite 700
Madison, WI 53703
608-267-0214
608-267-0368 FAX
http://www.disabilityrightswi.org/
Hon. Orrin Hatch, Hon. Ron Wyden, and Members of the United States
Senate Committee on Finance:
On behalf of Disability Rights Wisconsin (DRW), the Protection and
Advocacy system for people with disabilities, we urge you to reject the
Graham-Cassidy-Heller-Johnson proposal. Medicaid and the protections
provided by the Affordable Care Act are vital to people with
disabilities. This proposal will cut and cap Medicaid, eliminate
protections for people with pre-existing conditions, threaten Home and
Community Based Services relied upon by people with disabilities and
senior, permit annual and lifetime limits on health care coverage,
cause millions of Americans to lose their health insurance, and allow
states to waive Essential Health Benefits.
Here are some important facts about Wisconsinites with disabilities and
Medicaid programs:
One in five Wisconsinites who have a disability, are older
adults, are children, or are low-income working adults rely on Medicaid
for health care and other essential supports.
Wisconsin has 1.2 million people in Medicaid who could be hurt
by these cuts, including children with disabilities.
Children with disabilities rely on Medicaid for essential
therapies, prescription drugs, home and community based services, and
screening, diagnostic, and treatment services. Wisconsin has the lowest
per capita Medicaid spending on children in the nation and that rate
would be locked in.
Adults with a disability are more likely to be low-income, have
less access to health care, and report higher health risk factors and
chronic conditions.
Medicaid programs in Wisconsin (like BadgerCare, SeniorCare,
MAPP, Family Care, IRIS, children's waivers) help people with
disabilities and older adults with basic health care and therapies, and
often with daily living supports and personal cares like getting out of
bed, going to the bathroom, respite, help with meals, transportation,
and employment supports.
Home and Community Based Services, unlike institutional
services, are optional. But our HCBS Medicaid programs have allowed
thousands of Wisconsin residents with disabilities and older adults to
stay in their homes. By staying in their homes, they avoid costly
institutional care at significant savings to taxpayers.
Medicaid helps public schools provide special education services
and related services to 100,000 students in Wisconsin. School districts
in Wisconsin receive over $107 million dollars from Medicaid annually
for these important services.
DRW opposes the restructuring and capping of Medicaid funds.
The GCHJ would radically restructure Medicaid and divorce the federal
contribution from the actual costs of meeting people's health care
needs. The structure of GCHJ's cap--like the structure in previous
bills--makes cuts worse after it reduces the growth rate in 2025. The
Brookings Institution reports a projected reduction in Medicaid funding
to states of $713 billion through 2026, with steeper cuts the following
years, amounting to a $3.5 trillion cut by 2036 if block grant funding
is not reauthorized,\1\ and that such caps would cause tens of millions
of Americans to lose Medicaid coverage.
---------------------------------------------------------------------------
\1\ https://www.brookings.edu/research/how-will-the-graham-cassidy-
proposal-affect-the-number-of-people-with-health-insurance-coverage/.
Limited carve outs and targeted funding pots included in GCHJ pale in
comparison to the scope of these cuts. For example, GCHJ offers a 4-
year $8 billion dollar demonstration to expand. Medicaid home and
community-based services--which not even half of the $19 billion cut to
the Community First Choice option that eight states have implemented to
expand access to necessary in-home services for people with
disabilities. All individuals on Medicaid will be impacted by cuts to
this magnitude, despite any limited, temporary demonstration funding or
restricted funding carve out for a fraction of the children with
disabilities that Medicaid supports. Throwing billions in extra
temporary funds cannot curb the inevitable, long-term loss of critical
Medicaid services that people with disabilities will face as a result
---------------------------------------------------------------------------
of per capita caps.
DRW is deeply concerned that as more costs shift to the state in a
Medicaid per capita cap system, Wisconsin will need to implement
drastic cost-saving measures, such as creating wait lists for services,
reducing essential services and supports from the current benefit
package, cutting or restricting optional Home and Community Based
Services programs, or cutting provider rates.
The GCHJ bill threatens the progress that Wisconsin has made in
providing cost-effective services to adults and children with
disabilities through Medicaid.
Wisconsin has been a national leader in ending waiting lists for long
term care supports for adults and children with disabilities and frail
elders, as well as a historic expansion of community based mental
health and substance abuse disorder services. These cost-effective
investments have decreased reliance on costly institutional and crisis
services. People with disabilities rely on specific supports only
available to them through Medicaid. For decades, Wisconsin has made
progress supporting people with disabilities in home and community
based settings instead of in expensive institutional care facilities.
Wisconsin has already utilized significant flexibility under current
law that has led to cost-savings and innovation in our Medicaid
programs, including BadgerCare and Family Care and IRIS as waiver
programs.
While we agree that changes to Medicaid law that allow decisions to be
made closer to people's lives and needs is an important improvement,
the GCHJ proposal to change Medicaid to a per capita cap will not be
adequately funded to accomplish sustainable quality of care. Medicaid
per capita caps jeopardize decades of progress that have helped people
with disabilities reduce their health disparities, increase their
ability to live safely in their own homes, and experience improved
inclusion in Wisconsin community life.
DRW is concerned that allowing states to waive Essential Health
Benefits and permit annual and lifetime limits will harm people with
disabilities who access private health insurance.
Under the GCHJ, states would receive a short-term block grant (known as
a
Market-based Health Care Grant Program) to create their own health care
system. How these block grants would be structured and how they would
ultimately affect Wisconsinites and our state budget are entirely
unknown. However, the GCHJ would allow states to roll back a number of
consumer protections for people with pre-existing conditions, including
making essential benefits optional. Two and a half million
Wisconsinites have a pre-existing condition. If essential benefits are
not required, insurance plans will not be required to cover vital
services such as prescription drugs, hospitalization, outpatient
services, mental health services, and AODA treatment.
The Affordable Care Act has significantly improved access for children
and adults with disabilities to comprehensive and high quality private
insurance, thereby expanding opportunities to live independently and
maintain employment. Given its rollback of protections and limited
funds, the GCHJ proposal would likely result in plans that cover less
and cost more, limiting access for many people with disabilities who
have significant health care costs and a modest income. As insurance
coverage shrinks and its cost increases, Medicaid may be their only
option at a time when Medicaid funding is being slashed.
The GCHJ would allow states funds for high risk pools--but this funding
would NOT fix the loss of funding in Medicaid.
High Risk Insurance Pools have been tested--and have failed--in
Wisconsin. They could not provide affordable, comprehensive insurance
coverage for many people with disabilities and people with pre-existing
conditions. Wisconsin's experience with the health insurance risk
sharing plan (HIRSP) demonstrates that the high costs and limited
benefits associated with high-risk pool coverage resulted in delayed or
forgone care and adverse outcomes for enrollees. Many also accrued
medical debt despite having insurance. In addition, restrictive
eligibility requirements excluded many Wisconsinites with pre-existing
health conditions, and left them with no viable option for adequate
health insurance coverage. Wisconsin's old HIRSP is similar to the
high-risk insurance pools being proposed currently by Congress to cover
people with pre-existing conditions, and it failed to provide
affordable, comprehensive insurance coverage for many people.
Quickly moving forward with the GCHJ upends an ongoing bipartisan
process to address health care in the U.S. and does not allow for true
analysis to fully understand its' impact.
The Congressional Budget Office has not yet had a chance to assess the
impact the latest amendments will have on coverage, namely how many
Americans will lose coverage (or have more limited coverage) and the
actual cost of this proposal. It is fiscally irresponsible and
unethical to vote on such a wide-reaching and life-changing proposal
without this vital information.
We hope that any efforts to reform health care can move forward in a
bipartisan, transparent, and patient-centered manner and with people
with disabilities at the table. The following principles should be
incorporated into any future proposals:
People with pre-existing conditions must not be discriminated
against--either in access, premium setting, or cost sharing.
All essential health benefits currently covered by the ACA,
including habilitation services, and mental health and substance use
disorder services, must continue to be universally available.
The new system must be simple, straight forward, and at least as
easy to navigate as the ACA for people with disabilities.
Young adults must be permitted to stay on their parents'
policies until age 26.
There can be no annual or lifetime limits on coverage.
Maintain accessibility standards for diagnostic medical
equipment so people can access preventative health care screenings and
appropriate diagnostic testing.
Universal coverage must be maintained.
Funding of the new system cannot have a negative impact on
employer health plans as they cover working people with disabilities.
Information about and application for the replacement system
must be completely accessible to people with disabilities.
The provisions of the ACA that resulted in the closing of the
Medicare Part D ``donut hole'' must be retained.
We ask for continued bipartisan hearings on the topics of health care,
Medicaid, and community based long-term services and supports where the
voices and experiences of adults and children with disabilities are
included. Improving the ACA and improving health care for the country
should be the goal; moving forward with the GCHJ will only lead to harm
for millions of Americans, including people with disabilities. We
believe reform is possible without having to cut Medicaid, eliminate
health insurance coverage for people who have it, or remove protections
for people with preexisting conditions. Please feel free to contact me
if you would like to discuss these ideas further and meet with people
with disabilities who have ideas on how to improve our health care
system and who would be directly impacted by changes to Medicaid and
any other health care reform. We are available to share other common-
sense ideas to sustain Medicaid and to address the real cost drivers
for health care. In the meantime, we ask members of the U.S. Senate to
immediately reject the Graham-Cassidy-Heller-Johnson proposal because
of its harmful effects on Americans who rely on affordable and adequate
health care in their daily lives. We are especially concerned that
people with disabilities, many of whom rely on Medicaid coverage to
live full, healthy, and integrated lives in their communities will be
harmed when this proposal cuts Medicaid.
Respectfully,
Daniel Idzikowski Amy Devine
Executive Director Public Policy Coordinator
______
Doctors Organized for Healthcare Solutions
U.S. Senate
Committee on Finance
Dirksen Senate Office Bldg.
Washington, DC 20510-6200
September 19, 2017
Dear Chairperson Senator Orrin Hatch, Ranking Member Senator Ron Wyden,
and Members of the Committee:
Who We Are
We are 450 practicing physicians, all caring for over half a million
Americans in Cleveland, Ohio. We are not part of any formal medical
society or movement. Rather, these hundreds of doctors have met,
learned, and acted in response to the needs of the patients of our
community for over 13 years. Some have described DOCHS as the nation's
largest local group of volunteer physicians devoted to improved health
care policy, for the benefit of the patients we serve.
What We Stand For
1. No American should die for not being insured.
2. No American should go bankrupt for getting sick.
Our Concerns
Our concern is simply stated:
As practicing doctors, we seek policies that save lives and reduce
harm.
We know now that in today's America, not having insurance can cost you
your life.\1\,\2\ The level of that risk is now known as
well, it is in the range of 1:500. That is, for every 500 Americans cut
off from health care coverage, one will die. If a policy cuts 20
million Americans off insurance, it will lead to the death of 40,000
people. It is also true that if a policy adds 20 million people to
those insured, 40,000 lives will be saved.
---------------------------------------------------------------------------
\1\ Woolhandler, S., Himmelstein, D.U., ``The Relationship of
Health and Mortality: Is Lack of Insurance Deadly?'', Annals of
Internal Medicine, Doi: 10.7326/M17-1403, http://annals.org/aim, July
2017.
\2\ Sommers, B.D., Gawande, A.A., Baiker, K., ``Health Insurance
Coverage and Health--What the Recent Evidence Tells Us,'' New England
Journal of Medicine, Doi: 10.1056/NJEMsb1706645, August 2017.
This information reflects actual observations in a vast before-and-
after experiment, the passage of the ACA added millions to the number
insured, and mortality rates could then be examined, yielding the
results. It should be noted that with coverage came not only life,
bankruptcies from becoming ill dropped as much as 50%.
Our Recommendations
Our key recommendations derive from the two core values stated above.
As with our stated concerns, the 450 doctors of DOHCS do hope there is
no controversy, no partisan divide on these points. Every day, in our
exam rooms, we see patients seeking help when faced with serious health
challenges, not once have we seen a person come down with an illness
turn to us hoping they were not insured.
To reach these key recommendations we urge the United States Senate
Committee on Finance to adopt the following actions:
Given that the Affordable Care Act has left Americans in a better
situation to face inevitable illnesses than they faced 10 years ago,
and that the Affordable Care Act requires improvements if we are to
deliver to Americans actual health and financial security, we urge the
following steps be taken by the Committee on Finance:
1. Increase the percentage of Americans covered by health care
insurance every year.
2. Decrease the rate of rise, and actual amount of, health care
insurance premiums.
3. Stabilize the markets for those buying health care insurance as
individuals, not as employees (the exchanges).
4. Maintain the minimum standard of coverage defined by the ACA's
Essential Minimum Benefits.
5. Continue the elimination of pre-existing condition as a
concept.
6. Protect the integrity of Medicaid.
Further, DOHCS would be interested in looking at state waivers
(both 1115 and 1332) to the ACA but only if they do not violate the
above necessary steps. Waivers must increase the number of Americans
covered by health care insurance, decrease premium costs, and maintain
current essential health benefit definitions for plans.
We, the 450 doctors who care for over half a million Americans who live
in the Cleveland, Ohio area turn to you, members of the United States
Senate Committee on Finance, because more than anyone else at this
moment in time, you hold the fates of the people we care for in your
hands. Your hearings open a rare moment of opportunity to achieve real
progress, to make lives better, to reduce death from losing insurance,
and to reduce the risk of financial ruin from getting sick.
Our patients, right now, rely on the actions you will take. We, their
doctors, have made our recommendations and will be watching, on behalf
of our patients to see if you do save their lives.
Sincerely,
Arthur Lavin, M.D.
Michael Devereaux, M.D.
Co-Chairpersons, Doctors for Health Care Solutions
______
Two Real Life Scenarios From a Doctor: What Can Happen to a Child and a
Father Without Health Insurance
By Arthur Lavin, M.D.
September 2017
(This is based on real life experiences, but names and identifying
details are changed to protect privacy)
The Death of a 3 Year Old for Not being Insured
My toddler lies in my arms, and my husband and I know these are our
last moments with him.
His story began 3 years ago when we found out that after many years of
trying, I was finally pregnant, what a time to remember the joy we
felt, the doors opening to a future with a child. We were so happy
then.
About 3 months prior to delivery of our son, we found that he had a
rare heart defect, but the good news was that there were surgeons in
the country who could fix the problem. In the same day we were
terrified and offered real hope.
My husband works hard, as do I. Each of us have a job in the insurance
industry, doing mostly clerical work. We work hard, but don't make that
much money. Before our son was born, we were never all that worried
about health insurance, after all we are young and healthy, who needs
to worry?
But once we found our son had such a serious health condition, one that
held his precious life in its grip, we began to see insurance as one of
the most important resources, one that held our son's life in balance.
During those incredibly tense times, we were so glad to find out that
recent legislation opened the door to hard-working families like ours
to obtain insurance that would open the door to our son getting his
life-saving surgery.
It turned out to be more difficult that we ever could imagine. Soon
after he was born, a law passed some years ago in Congress went into
effect. Our family lost its insurance. We were told when it passed that
a brilliant future awaited, that we would chuck government provided
insurance and we would see the flowering of new plans that the free
market would create. I don't know much about how all that works, all I
know is that now, when our child's life hung in the balance, the GOP
health plan has cut us off.
Without insurance we have spent all we could raise to see specialists,
and we have depended on the free care ER's have had to provide during
the emergencies we experienced. Our son has spent his whole life very
blue, since his heart condition keeps oxygen from getting to his body.
The specialists have helped, they have prescribed medicines that have
kept him alive for the first months of life, and the ER's have taken
life-saving actions. But Andrew can't live without the special surgery,
and that surgery costs over $250,000. We don't have the money, and our
country has told us they cannot help.
Who can believe it, but solely because of a law passed, my husband and
I are now sitting at home with our dear Andrew on our laps, watching
him struggle to breathe. Over time, the lack of oxygen has stunted his
growth, so although he is 15 months old, he barely weighs over 10
pounds. What makes this all so unbearable are memories of sitting in
our specialist's waiting room and seeing older kids with a similar
problem, who had insurance before the GOP plan went into effect, who
got their surgery, and are running around the office.
That could have been Andrew, but instead, Andrew has been sentenced to
this tragic end. As we prepare for the last moments, we try to comfort
Andrew who is far more blue than ever, each breath takes all he has
just to get it in and out of his frail body. He is clearly so
uncomfortable. As he has gotten older, and his body was withered, his
eyes seem to get bigger and they turn to us with all the love he has
always had for us. There is some comfort in that connection.
Soon, his breaths become more irregular, and turn into gasps. His body
shakes, and we know the end is near. After a few hours, he eyes close
and we begin to hug him goodbye. A few more gasps and Andrew is no
more.
This scenario represents one of the estimated 44,000 deaths that will
occur if the GOP health bill becomes law. We know the official
estimates establish that 22 million Americans will lose health
insurance as a result of this bill, and that about 1 in 500 people who
lose insurance will die as a result of this happening. Andrew's story
will be one of these 44,000 stories.
What sort of country, what sort of people, would support stripping
Andrew of his life-saving surgery, and handing that $250,000 over to a
handful of already astoundingly wealthy people? Apparently that country
is America, and those people are us. We have a lot to answer to the Mom
and Dad of Andrew. May we find the courage and ability to stop this
from happening to them.
______
The Death of a 35 Year Old Because He Had No Insurance
Michael was a very healthy young man in his thirties. In 2007, he found
health insurance too expensive to purchase and given his health, he
decided not to purchase any.
In the summer of that year he found a mole on his skin that seemed to
be larger than usual with some darkening of its color. He felt fine, in
fact he was recently engaged. Later that year he was married and early
in 2008 his wife became pregnant. During that year, the mole kept
growing and by the fall, he decided to go to the ER, where he know care
could be covered.
The ER found the mole looked deeply worrisome, and had a dermatology
team come to see him while he was at the ER. The team biopsied the mole
and found it was melanoma. Not only was it melanoma, but the cancer had
spread deep into the skin.
At this time, he tried to obtain health insurance, but no plan would
cover his melanoma, it was considered a ``pre-existing condition.'' But
with his life at stake, just as his family was forming, he proceeded
with the very expensive process of completing his diagnostic processes
and initiating the urgently required therapies.
As his wife's pregnancy progressed, Michael found that his melanoma had
spread not only deeply into his skin, but through his body. He and his
wife were stunned. Had he seen a doctor the prior summer, they now knew
the melanoma might have been removed in plenty of time to remove a
potential threat to his life. They also knew he delayed this
appointment because he had no insurance.
With diagnosis complete, Michael began his therapies. Options were
limited given how advanced the melanoma had spread. The therapies
slowed the progress of the cancer, but it was far too late to stop it.
By the end of 2008 Michael was deadly ill.
Fortunately the therapies did slow the progress of cancer sufficiently
to allow him to be alive to see the birth of his healthy and happy baby
son. His wife and his son were the bright spots in his diminishing
life.
Three months after their baby was born, Michael began to slip into loss
of organ function that would in a few weeks take his life.
Michael knew this was happening, and so did his wife. They clung to
each moment of time together, he was astounded every day to see the
progress his son was making, knowing these steps would be the last he
would be privileged to share, to be alive to see.
One evening, Michael began to struggle to breath. His wife, now a new
mother, held him in her arms. She played their special songs and she
sang to him. Their baby boy was in a bassinet right next to his father,
Michael. As she sang, Michael felt a warm ease begin to settle over
him, his breathing calmed, and grew more shallow. Michael and his wife
knew was the end, and they gazed into each other's eyes as he took his
last breath and then breathed no more. He shook in her arms as she
wept.
Now the son has become a young school aged boy. He still misses his
Daddy, and his Mom continues to wonder why his death had to be.
Again, this scenario represents one of the estimated 44,000 deaths that
will occur if the GOP health bill becomes law. We know the official
estimates establish that 22 million Americans will lose health
insurance as a result of this bill, and that about 1 in 500 people who
lose insurance will die as a result of this happening. And so Michael's
story will be one of these 44,000 stories.
What sort of country, what sort of people, would support stripping
Michael of life-saving melanoma detection services, and handing the
cost of this simple service to a handful of incredibly wealthy people?
Once again the answer is that apparently that country is America, and
those people are us. We have a lot to answer to this family. May we
find the courage and ability to stop this from happening to those in
the same position.
______
Annals of Internal Medicine Medicine and Public Issues
The Relationship of Health Insurance and Mortality: Is Lack of
Insurance Deadly?
Steffie Woolhandler, M.D., MPH, and David U. Himmelstein, M.D.
About 28 million Americans are currently uninsured, and millions more
could lose coverage under policy reforms proposed in Congress. At the
same time, a growing number of policy leaders have called for going
beyond the Affordable Care Act to a single-payer national health
insurance system that would cover every American. These policy debates
lend particular salience to studies evaluating the health effects of
insurance coverage. In 2002, an Institute of Medicine review concluded
that lack of insurance increases mortality, but several relevant
studies have appeared since that time. This article summarizes current
evidence concerning the relationship of insurance and mortality. The
evidence strengthens confidence in the Institute of Medicine's
conclusion that health insurance saves lives: The odds of dying among
the insured relative to the uninsured is 0.71 to 0.97.
Ann Intern Med. doi:10.7326/M17-1403
Annals.org
For author affiliations, see end of text.
This article was published at Annals.org on 27 June 2017.
_______________________________________________________________________
At present, about 28 million Americans are uninured. Repeal of the
Affordable Care Act would probably increase this number, while
enactment of proposed single-payer legislation (1) would reduce it. The
public spotlight on how policy changes affect the number of uninsured
reflects a widespread assumption that insurance improves health.
A landmark 2002 Institute of Medicine (IOM) report on the effects
of insurance coverage on the health status of nonelderly adults
buttressed this assumption (2). The IOM committee responsible for the
report found consistent evidence from 130 (mostly observational)
studies that ``the uninsured have poorer health and shortened lives''
and that gaining coverage would decrease their all-cause mortality (2).
The IOM committee also reviewed evidence on the effects of health
insurance in specific circumstances and medical conditions. It
concluded that uninsured patients, even when acutely ill or seriously
injured, can not always obtain needed care and that coverage improves
the uptake of essential preventive services and chronic disease
management. The report found that uninsured patients with cancer
presented with more advanced disease and experienced worse outcomes,
including mortality; that uninsured patients with diabetes,
cardiovascular disease, end-stage renal disease, HIV infection, and
mental illness (the five other conditions reviewed in depth) had worse
outcomes than did insured patients; and that uninsured inpatients
received less and worse-quality care and had higher mortality both
during their hospital stays and after discharge.
At the time of the IOM report, only one adequately controlled
observational study had examined the effect of coverage on all-cause
mortality. In this review, we summarize key evidence on this issue
(Table 1), focusing on studies that have appeared since the IOM report
and other previous reviews (3-6). Although not reviewed in detail here,
more recent studies generally support the earlier reviews' conclusions
that insurance coverage improves mortality in several specific
conditions (such as trauma [7] and breast cancer [8]), augments the use
of recommended care (9), and improves several measures of health status
(10, 11).
Methods
We searched PubMed and Google Scholar on May 19, 2017, for English-
language articles by using the following terms: ``[(uninsured) or
(health insurance) or (uninsurance) or (insurance)] and [(mortality) or
(life expectancy) or (death rates)].'' After identifying relevant
articles, we searched their bibliographies and used Google Scholar's
``cited by'' feature to identify additional relevant articles. We
limited our scope to articles reporting data on the United States,
quasi-experimental studies of insurance expansions in other wealthy
nations, and recent cross-national studies. We contacted the authors of
4 studies to clarify their published reports on mortality outcomes.
We excluded most observational studies that compared uninsured persons
with those insured by Medicaid, Medicare, or the Department of Veterans
Affairs because preexisting disability or illness can make an
individual eligible for these programs. Hence, relative to those who
are uninsured, publicly insured Americans have, on average, worse
baseline health, thereby confounding comparisons. Conversely,
comparisons of the uninsured to persons with private insurance (which
is often obtained through employment) may be confounded by a ``healthy
worker'' effect: that is, that persons may lose coverage because they
are ill and cannot maintain employment. Nonetheless, most analysts of
the relationship between uninsurance and mortality have viewed the
privately insured as the best available comparator, with statistical
controls for employment, income, health status, and other potential
confounders.
Finally, we focus primarily on nonelderly adults because most studies
have been limited to this group, and this group is likely to experience
large gains or losses of coverage from health reforms. Since the advent
of Medicare in 1966, almost all elderly Americans have been covered,
precluding studies of uninsured seniors. Although Medicare's
implementation may not have accelerated the secular decline in seniors'
mortality (12), the relevance of this experience, which predates many
modern-day therapies, is unclear.
Children have also been excluded from most recent analyses of the
relationship of insurance to mortality. Deaths in this population
beyond the neonatal period are so rare that studies would need to
evaluate a huge number of uninsured children to reach firm conclusions,
and high coverage rates make assembling such a cohort difficult. The
few studies addressing the effect of insurance on child survival have
found that coverage lowers mortality (13-15) and few policy leaders
contest the importance of covering children.
Randomized, Controlled Trials
Only one well-conducted randomized, controlled trial (RCT)--the Oregon
Health Insurance Experiment (OHIE)--has assessed the effect of
uninsurance on health outcomes (10, 16). In 2008, the state of Oregon
opened a limited number of Medicaid slots to poor, able-bodied,
uninsured adults aged 19 to 64 years. The state held a lottery among
persons on a Medicaid waiting list, with winners allowed to apply for a
slot. The OHIE researchers took advantage of this natural experiment to
assess the effect of winning the lottery on the 74,922 lottery
participants.
Many lottery winners did not enroll in Medicaid, and 14.1% of lottery
losers obtained Medicaid through other routes (some also got private
coverage). Hence, the difference in the ``dose'' of Medicaid coverage
was modest, an absolute difference of about 25%; to adjust for this,
the OHIE researchers multiplied outcome differences by about 4 (10).
At 1 year of follow-up, the death rate among lottery losers was 0.8%,
and the winners' death rate was 0.032% lower, a ``dose-adjusted''
difference of 0.13 percentage points annually (17). This difference was
not statistically significant, an unsurprising finding given the OHIE's
low power to detect mortality effects because of the cohort's low
mortality rate, the low dose of insurance, and the short follow-up.
The findings on other health measures, obtained from in-person
interviews and brief examinations on a subsample of 12,229 individuals
in the Portland area, help inform the mortality results. Most physical
health measures were similar among lottery winners and losers in the
subsample. However, winners had better self-rated health, were more
likely to have diabetes diagnosed and treated with medication, and were
much less likely to screen positive for depression (10). Medicaid
coverage was associated with a nonsignificant decrease of 0.52 (95% CI,
2.97 to -1.93) mm Hg in systolic blood pressure and 0.81 (95% CI, 2.65
to -1.04) mm Hg in diastolic blood pressure (10). In addition to the
low dose of insurance, these wide CIs reflect the lack of baseline
blood pressure data; this precludes analyses that take advantage of
paired measures on each individual, which would reduce the variance of
estimates.
In sum, the OHIE yields a (nonsignificant) point estimate that Medicaid
coverage reduced mortality by 0.13 percentage points, equivalent to a
(nonsignificant) odds ratio of 0.84.
_______________________________________________________________________
Key Summary Points
In several specific conditions, the uninsured have worse survival, and
the lack of coverage is associated with lower use of recommended
preventive services.
The Oregon Health Insurance Experiment, the only available randomized,
controlled trial that has assessed the health effects of insurance,
suggests that insurance may cause a clinically important decrease in
mortality, but wide CIs preclude firm conclusions.
The two National Health and Nutrition Examination Study analyses that
include physicians' assessments of base-line health show substantial
mortality improvements associated with coverage. A cohort study that
used only self-reported baseline health measures for risk adjustment
found a nonsignificant coverage effect.
Most, but not all, analyses of data from the longitudinal Health and
Retirement Study have found that coverage in the near-elderly slowed
health decline and decreased mortality.
Two difference-in-difference studies in the United States and one in
Canada compared mortality trends in matched locations with and without
coverage expansions. All three found large reductions in mortality
associated with increased coverage.
A mounting body of evidence indicates that lack of health insurance
decreases survival, and it seems unlikely that definitive randomized,
controlled trials can be done. Hence, policy debate must rely on the
best evidence from observational and quasi-experimental studies.
_______________________________________________________________________
Two older RCTs are also relevant to the effect of insurance and access
to care on mortality, although neither directly compared insured and
uninsured persons. In the RAND Health Insurance Experiment, random
assignment to full (first-dollar) coverage reduced diastolic blood
pressure by an average of 0.8 mm Hg (P < 0.05) relative to persons
randomly assigned to plans that required cost sharing (18), an effect
size similar to the blood pressure findings in the OHIE. Unlike the
OHIE, the RAND Health Insurance Experiment obtained base line blood
pressure readings, allowing researchers to determine that for
participants with hypertension at baseline, full coverage reduced
diastolic blood pressure by 1.9 mm Hg, mostly because of better
hypertension detection (19); the effect was larger among low income
(3.5 mm Hg) than high-income (1.1 mm Hg) participants (19).
The Hypertension Detection and Follow-up Program also suggests that
removing financial barriers to primary care in populations with high
rates of uninsurance may reduce mortality. That population-based RCT
carried out in the 1970s screened almost all residents of 14
communities, with oversampling of predominantly black and poor
locations. Persons with hypertension were randomly assigned to free
stepped care in special clinics or referral to usual care. Although the
clinics' staff treated only hypertension-related problems, they
provided informal advice and ``friendly referrals'' for other medical
issues (20). Strikingly, all-cause mortality was reduced by 17% in the
intervention group, with similar reductions in deaths due to
cardiovascular and noncardiovascular conditions (21).
Table 1. Summary of Studies on Relationship Between Insurance Coverage
Pand All-Cause Mortality *
Estimated
Mortality
Study, Year Information Effect of
(Reference) Participants on Baseline Coverage Comments
Health vs.
Uninsured
RCTs
Oregon 74,922 Retrospective OR, 0.84 Study was
Health nondisabled survey of a (NS) underpowered
Insurance adults on subsample; because of
Experiment waiting list no baseline crossovers
, 2013, for Medicaid blood between
2011, 2012 pressure or insured and
(10, 16, other uninsured
17) measurements groups, low
mortality
rate, short
follow-up.
Coverage was
associated
with
nonsignifican
tly lower
(0.81 mm Hg)
average
diastolic
blood
pressure
Quasi-
experimental
studies,
population-
based
Sommers et Nonelderly None at RR of Study examined
al., 2012, adults in individual death Medicaid
2017 (29, states level; expansion/ expansions
30) expanding compared nonexpans that preceded
Medicaid trends in ion the ACA's
(Arizona, New death rates states, expansions
York, Maine) in expansion 0.939 (P
and with those = 0.001)
comparison in
states neighboring
states
Sommers et Nonelderly None at RR for The 2006
al., 2014 adults in individual death in reform
(31) Massachusetts level; Massachus expanded
and compared etts Medicaid and
comparison trends in counties/ implemented
counties death rates matched subsidized
in counties, coverage for
Massachusett 0.971 (P low-income
s with those = 0.003) persons
in matched
control
counties
Hanratty, Newborns in None at RR for Estimates
1996 (51) Canadian individual death, varied
provinces level; 0.95 or slightly
expanding compared 0.96 (P depending on
coverage at infant < 0.05 how time
different mortality for both) trends were
times trends pre- modeled
vs.
postreform
Quasi-
experimental
studies,
clinic
cohorts
Lurie et 186 clinic Clinic-based OR at 1 y, Large effect
al., 1984, patients data 0.23 (NS) probably
1986 (40, terminated reflects very
41) from Medicaid high baseline
vs. 109 who risk. Among
remained terminated
eligible patients with
hypertension,
average
diastolic
blood
pressure
increased 10
mm Hg at 6 mo
vs. decrease
of 5 mm Hg
among
controls (P =
0.003)
Fihn and 157 patients Clinic-based OR not Marked
Wicher, terminated data calculabl deterioration
1988 (42) from e from in blood
outpatient VA published pressure
care vs. 74 data; per control among
controls authors, terminated
``at patients
least 6%
of
terminate
d
patients
died''
Quasi- Several Repeated Conflictin Studies
experiment cohorts questionnair g compared
al studies followed for es linked to results; mortality
using varying time Medicare some before age 65
longitudin periods from records and found y and
al data age 51y National lower relative
from the Death Index; deaths changes in
Health and no among death rates
Retirement examination insured, after
Study (26, or and acquisition
32-37) laboratory others of Medicare
data were null eligibility.
Different
analytic
strategies
yielded
different
conclusions
Population-
based cohort
follow-up
studies
Sorlie et CPS None other HR for No data on
al., 1994 respondents than being employed smoking,
(23) 1982-1985 employed white health status
women, or other non-
0.83 demographic
(NS); HR predictors of
for mortality at
employed baseline
white
men, 0.77
(P =
0.05)
Franks et NHANES Surveys, HR, 0.8 (P Controls for
al., 1993 respondents physical = 0.05) baseline
(27) 1971-1975 examinations health status
, and lab included
test results physician-
assessed
morbidity
Kronick, NHIS Questionnaire HR, 0.91 Control for
2009 (24) respondents s only P(P < sell-rated
1986-2000 0.05; health may
without bias findings
control because this
for self- variable is
rated probably
health) confounded by
and 0.97 coverage
(NS;
including
self-
rated
health)
Wilper et NHANES Surveys and HR, 0.71 Controls for
al, 2009 respondents physician- P(P < baseline
(28) 1988-1994 rated health 0.05) health status
after a included
physical physician-
examination assessed
health status
ACA = Affordable Care Act; CPS = Current Population Survey; HR = hazard
ratio; NHANES = National Health and Nutrition Examination Study; NHIS
= National Health Interview Survey; NS = nonsignificant; OR = odds
ratio; RR = relative risk; VA = Department of Veterans Affairs.
* For studies not reporting ORs, HRs, or RRs, the authors computed them
from data in the original report.
Finally, a flawed RCT carried out by the Social Security Administration
starting in 2006 bears brief mention. That study randomly assigned
people who were receiving Social Security disability income and were in
the waiting period for Medicare coverage to receive immediate or
delayed coverage (22). Unfortunately, randomization apparently failed,
with many more patients with cancer assigned to the immediate coverage
than to the control group, precluding reliable interpretation of the
mortality results (11). Interestingly, persons receiving immediate
coverage had rapid and significant improvements in most measures of
self-reported health (11).
Mortality Follow-Up of Population-Based Health Surveys
Several routinely collected federal surveys that include information
about health insurance coverage have been linked to the National Death
Index, allowing researchers to compare the mortality rates over several
years of respondents with and without coverage at the time of the
initial survey. One weakness of these studies is their lack of
information about the subsequent acquisition or loss of coverage, which
many people cycle into and out of over time. This dilutes coverage
differences and may lead to underestimation of the effects of insurance
coverage.
Sorlie and colleagues (23) analyzed mortality among respondents to the
1982-1985 Current Population Survey, with follow-up through 1987. In
analyses limited to employed persons, the relative risk for death
associated with being uninsured was 1.3 for white men and 1.2 for white
women (neither overall figures nor those for minorities were reported)
(23). The study's lack of data on important determinants of health,
such as smoking, and its reliance on employment status as the only
proxy for baseline health status weaken confidence in its conclusions.
Kronick used data from the 1986-2000 National Health Interview Surveys,
with mortality follow-up through 2002 (24). The mortality hazard ratio
for uninsured versus insured individuals was 1.10 (95% CI, 1.03 to
1.19) after adjustment for demographic variables, smoking, and body
mass index. The hazard ratio fell to 1.03 (95% CI, 0.95 to 1.12) after
additional adjustment for baseline health, defined by using self-
reported disability and self-rated health. Although the self-rated
health scale is known to be a valid predictor of mortality (25), it may
introduce inaccuracies in comparisons of uninsured versus insured
persons. Recent data (10, 11, 16, 26) indicate that gaining coverage
improves self-rated health, before improvements in objective measures
of physical health are detectable (or plausible). This suggests that
uninsurance may cause people to underrate their health, perhaps because
of anxiety or the inability to gain reassurance about minor symptoms.
Analyses, such as Kronick's, that rely on self-rated health for risk
adjustment therefore may inadvertently compare relatively sick insured
persons to relatively healthy uninsured persons, obscuring outcome
differences caused by coverage. Studies that include more objective
measures of baseline health should be less subject to any such bias.
Mortality Follow-Up of Population-Based Health Examination Surveys
Two studies have analyzed the effect of uninsurance on mortality using
data from the National Health and Nutrition Examination Survey
(NHANES), which obtains data from physical examination and laboratory
tests among participants.
Franks and colleagues (27) analyzed the 1971-1975 NHANES, with
mortality follow-up through 1987. They compared mortality of uninsured
and privately insured adults older than age 25 years, adjusted for
demographic characteristics, self-rated health, smoking, obesity,
leisure time exercise, and alcohol consumption. In addition, their
models controlled for evidence of morbidity determined by laboratory
testing and medical examinations performed by NHANES staff. By 1987,
9.6% of the insured and 18.4% of the uninsured had died. After
adjustment for baseline characteristics and health status, the hazard
ratio for uninsurance was 1.25 (95% CI, 1.00 to 1.55).
Wilper and colleagues' study (which we coauthored) used data from the
1988-1994 NHANES, with mortality follow-up through 2000 (28). The study
assessed mortality among uninsured and privately insured persons age 17
to 64 years, controlling for demographic characteristics, smoking,
alcohol consumption, body mass index, leisure time activity, self-rated
health, and physician-rated health after the NHANES physician completed
the medical examination. The study also included sensitivity analyses
adjusting for the number of hospitalizations and physician visits
within the past year, limitations in work or activities, job or
housework changes due to health problems, and number of self-reported
chronic diseases, which yielded results similar to those of the main
model. In the main model, being uninsured was associated with a
mortality hazard ratio of 1.40 (95% CI, 1.06 to 1.84).
Quasi-Experimental Studies of State and Provincial Coverage Expansions
In two similar studies (29, 30), Sommers and colleagues compared
mortality trends in states that expanded coverage to low-income
residents (before implementation of the Affordable Care Act) with
trends in similar states without coverage expansions.
Their analysis of Medicaid expansions in Maine, New York, and Arizona
during the early 2000s found that adult mortality rates fell faster in
those states than in neighboring ones (a relative reduction of 6.1%, or
19.6 deaths per 100,000), coincident with a decline in the uninsurance
rate of 3.2 percentage points (29). Mortality reductions were largest
among nonwhites, adults age 35 to 64 years, and poorer counties.
Sommers and colleagues' subsequent reanalysis using data that allowed
better matching to control counties yielded a slightly lower estimate
of the mortality effect (30). As the authors note, the large mortality
effect from a relatively modest coverage expansion may reflect the fact
that Medicaid enrollment often occurred ``at the point of care for
patients with acute illnesses'' leading to the selective enrollment of
those most likely to benefit from coverage.
A study of the effect of Massachusetts' 2006 coverage expansion
compared mortality trends in Massachusetts counties with those in
propensity score-matched counties in other states. Mortality decreased
by 2.9% in Massachusetts relative to the comparison counties, a
difference of 8.2 deaths per 100,000 adults, with larger declines in
poorer counties and those with lower coverage rates before the
expansion (31).
Other Quasi-Experimental Studies
Several researchers have used data from the Health and Retirement Study
(HRS)--a longitudinal study that has followed cohorts enrolled at age
51 years or older--to assess the effect of insurance coverage on
mortality. The HRS periodically survey respondents and their families
and has been linked to Medicare and National Death Index data.
McWilliams and colleagues found significantly higher mortality rates
among uninsured compared with insured HRS respondents, even after
propensity score adjustment for multiple predictors of insurance
coverage (32). Baker and colleagues found that respondents who were
uninsured (compared with those who had private insurance) had higher
long-term but not short-term mortality (33). After adjustment for
multiple base-line characteristics, including instrumental variables
associated with coverage (such as a spouse's union membership), Hadley
and Waidmann found a strong positive association between insurance
coverage and survival before age 65 years (34). Black and colleagues
suggested, on the basis of a ``battery of causal inference methods,''
that others overestimated the survival benefits of insurance and that
uninsured HRS respondents had only slightly higher (adjusted) mortality
than those with private coverage (35). Finally, studies have reached
conflicting conclusions as to whether the health of previously
uninsured persons improves (relative to those who were previously
insured) after they reach age 65 years and become eligible for Medicare
(26, 36). Overall, the preponderance of evidence from the HRS suggests
that being uninsured is associated with some increase in mortality.
Some studies using other data sources suggest that death rates drop at
age 65 years, coincident with the acquisition of Medicare eligibility
(37, 38), whereas others do not (39).
Finally, several studies have assessed the relationship between
insurance coverage and hypertension control, a likely mediator of any
relationship between coverage and all-cause mortality. Lurie and
colleagues (40) followed a cohort of 186 patients who lost Medicaid
coverage because of a statewide policy change and a control group of
109 patients who remained eligible. Among those who lost coverage, five
died within 6 months (compared with none in the control group; P =
.16), and the average diastolic blood pressure of those with
hypertension increased by 10 mm Hg (compared with a 5-mm Hg decrease in
controls; P = 0.003) (40). At 1 year, seven patients who had lost
Medicaid and one control had died; blood pressure differences were
slightly less marked than seen at 6 months (41). A similar study of
patients terminated from Veterans Affairs outpatient care because of a
budget shortfall found marked deterioration in hypertension control
among the terminated patients relative to controls who maintained
access (42). These clinic-based findings accord with cross sectional
population-based analyses of data from NHANES, which have found worse
blood pressure control among uninsured than insured patients with
hypertension (43-45).
Evidence From Other Nations and From Cross-National Studies
The United States lags behind most other wealthy nations in life
expectancy and is the only one with substantial numbers of uninsured
residents (46). Although many factors confound cross-national
comparisons, a recent study suggests that worse access to good-quality
health care contributes to our nation's higher mortality from medically
preventable causes (so-called amenable mortality) (47). Similarly, a
recent review of studies from many nations concluded that ``broader
health coverage generally leads to better access to necessary care and
improved population health.'' (48)
Quasi-experimental studies assessing newly implemented universal
coverage in wealthy nations have reached similar conclusions. For
instance, Taiwan's roll-out of a single-payer system in 1995 was
associated with an accelerated decline in amenable mortality,
particularly in townships where coverage gains were larger (49, 50). In
Canada, a study exploiting the different dates on which provinces
implemented universal coverage estimated that coverage expansion
reduced infant mortality by about 5% (P < 0.03) (51).
Finally, a recent study of cystic fibrosis cohorts also suggests that
coverage improves mortality. Such patients live, on average, 10 years
longer in Canada than in the United States. Among U.S. patients, those
without known coverage have the shortest survival; among the privately
insured, life expectancy is similar to that among patients in Canada
(52).
Table 2. Why the Causal Relationship of Health Insurance to Mortality Is
Hard to Study
------------------------------------------------------------------------
-------------------------------------------------------------------------
Deaths, especially from causes amenable to medical treatment, are rare
among nonelderly adults, who account for most of the uninsured.
Because insurance might prevent death by slowing the decline in health
over several years, short-term studies may underestimate its effects.
Many people cycle in and out of insurance, diluting differences between
groups.
Randomly assigning participants to no coverage is unethical in most
circumstances.
Observational studies must address reverse causality. Illness sometimes
causes people to acquire public insurance by qualifying them for
Medicaid, Medicare, or Department of Veterans Affairs disability
coverage. Conversely, illness may cause job loss and resultant loss of
private coverage.
In cohort studies, adequate control for baseline health status is
difficult, particularly in uninsured patients, whose lack of access
lowers self-rated health and also causes less awareness of important
risk factors, such as hypertension or hyperlipidemia.
Quasi-experimental studies, which exploit factors associated with
coverage (such as policy changes), rest on unverifiable assumptions
(e.g., that without a coverage expansion, mortality trends in states
expanding coverage would parallel those in a comparator state).
------------------------------------------------------------------------
DISCUSSION
The evidence accumulated since the publication of the IOM's report in
2002 supports and strengthens its conclusion that health insurance
reduces mortality. Several newer observational and quasi-experimental
studies have found that uninsurance shortens survival, and a few with
null results used confounded or questionable adjustments for baseline
health. The results of the only recent RCT, although far from
definitive, are consistent with the positive findings from cohort and
quasi-experimental analyses.
Several factors complicate efforts to determine whether uninsurance
increases mortality (Table 2). Randomly assigning people to uninsurance
is usually unethical, and quasi-experimental analyses rest on
unverifiable assumptions. Deaths are rare and mortality effects may be
delayed, mandating large studies with long follow-up. Many people cycle
into and out of coverage, diluting the effects of insurance. And
statistical adjustments for baseline health usually rely on
participants' self-reports, which may be influenced by coverage. Hence,
such adjustments may under- or overadjust for differences between
insured and uninsured persons.
Inferences about mechanisms through which insurance affects mortality
are subject to even greater uncertainty. In some circumstances,
coverage might raise mortality by increasing access to dangerous drugs
(such as oral opioids) or procedures (such as morcellation
hysterectomy). On the other hand, coverage clearly reduces mortality in
several serious conditions, although few are common enough to have a
detectable effect on population-level mortality. The exception is
hypertension, which is prevalent among the uninsured and seems a likely
contributor to their higher death rates. Although uncontrolled
hyperlipidemia is also more common among the uninsured (44), the OHIE--
the only RCT performed in the statin era-found no effect of coverage on
cholesterol levels.
Finally, our focus on mortality should not obscure other well-
established benefits of health insurance: improved self-rated health,
financial protection, and reduced likelihood of depression. Insurance
is the gateway to medical care, whose aim is not just saving lives but
also relieving human suffering.
Overall, the case for coverage is strong. Even skeptics who suggest
that insurance doesn't improve out comes seem to vote differently with
their feet. As one prominent economist (53) recently asked, ``How many
of the people who write such things . . . choose to just not bother
getting their healthcare?''
From The City University of New York School of Urban Public Health at
Hunter College, New York, New York, and Harvard Medical School, Boston,
Massachusetts.
Disclosures: Drs. Woolhandler and Himmelstein report serving as unpaid
advisors to Bernie Sanders' presidential campaign and were founders of
and remain active in Physicians for a National Health Program, an
organization that advocates for
single-payer reform. Forms can be viewed at www.acponline.org/authors/
icmje/ConflictOfInterestForms.do?msNum=M17-1403.
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______
From The New England Journal of Medicine
Sounding Board
Health Insurance Coverage and Health--
What the Recent Evidence Tells Us
Benjamin D. Sommers, M.D., Ph.D., Atul A. Gawande, M.D., M.P.H., and
Katherine Baicker, Ph.D.
The national debate over the Affordable Care Act (ACA) has involved
substantial discussion about what effects--if any--insurance coverage
has on health and mortality. The prospect that the law's replacement
might lead to millions of Americans losing coverage has brought this
empirical question into sharp focus. For instance, politicians have
recently argued that the number of people with health insurance is not
a useful policy metric \1\ and that no one dies from a lack of access
to health care.\2\ However, assessing the impact of insurance coverage
on health is complex: health effects may take a long time to appear,
can vary according to insurance benefit design, and are often clouded
by confounding factors, since insurance changes usually correlate with
other circumstances that also affect health care use and outcomes.
Nonetheless, over the past decade, high quality studies have shed light
on the effects of coverage on care and health. Here, we review and
synthesize this evidence, focusing on the most rigorous studies from
the past decade on the effects of coverage for nonelderly adults.
Previous reviews have provided a thorough discussion of older
studies.\3\ We concentrate on more recent experimental and quasi-
experimental studies of the ACA and other expansions of public or
private insurance. The effects of coverage probably vary among people,
types of plans, and settings, and these studies may not all directly
apply to the current policy debate. But as a whole, this body of
research (Table 1) offers important insights into how coverage affects
health care utilization, disease treatment and outcomes, self-reported
health, and mortality.
FINANCIAL PROTECTION AND THE ROLE OF INSURANCE
Before we assess these effects, it is worth recognizing the role of
insurance as a tool for managing financial risk. There is abundant
evidence that having health insurance improves financial security. The
strongest evidence comes from the Oregon Health Insurance Experiment, a
rare randomized, controlled trial of health insurance coverage.\31\ In
that study, people selected by lottery from a Medicaid waiting list
experienced major gains in financial well-being as compared with those
who were not selected: a $390 average decrease in the amount of medical
bills sent to collection and a virtual elimination of catastrophic out-
of-pocket expenses.\4\, \8\ Studies of other insurance
expansions, such as Massachusetts' 2006 health care reform,\7\ the
ACA's 2010 ``dependent-coverage provision'' enabling young adults to
stay on a parent's plan until age 26,\6\ and the ACA's 2014 Medicaid
expansion,\5\ have all revealed similar changes, including reduced bill
collections and bankruptcies, confirming that insurance coverage
reduces the risk of large unpredictable medical costs.
But from a policy perspective, health insurance is viewed differently
from most other types of insurance: there is no push, for example, for
universal homeowners' or renters' insurance subsidized by the federal
government. We contend that there are two reasons for this difference.
First, policymakers may value publicly subsidized health insurance as
an important part of the social safety net that broadly redistributes
resources to lower-income populations. Second, policymakers may view
health insurance as a tool for achieving the specific policy priority
of improved medical care and public health. Evaluating the impact of
insurance coverage on health outcomes--and whether these benefits
justify the costs of expanding coverage--is our focus.
Table 1. Evidence on the Effects of Health Insurance on Health Care and
Health Outcomes, 2007-2017
------------------------------------------------------------------------
Insurance or Policy
Domain and Findings Examined * Studies
------------------------------------------------------------------------
Financial security
Reduction in medical Medicaid Baicker et al. 2013;\4\
bills sent to Hu et al. 2016 \5\
collection and in
catastrophic medical
spending
Reduced out-of-pocket DCP, Medicaid Chua and Sommers
medical spending 2014;\6\ Baicker et al.
2013 \4\
Reduced personal MA Mazumder and Miller 2016
bankruptcies and \7\
improved credit
scores
Access to care and
utilization
Increased outpatient Medicaid, MA Finkelstein et al.
utilization and 2012;\8\ Sommers et al.
rates of having a 2014;\9\ Simon et al.
usual source of care/ 2017 \10\
personal physician
Increased preventive Medicaid, MA Baicker et al. 2013;\4\
visits and some Sommers et al. 2014 and
preventive services 2016;\9\,\11\ Simon et
including cancer al. 2017 \10\
screening and lab
tests
Increased Medicaid Ghosh et al. 2017;\12\
prescription drug Sommers et al. 2016
utilization and \11\
adherence
Mixed evidence on Medicaid, DCP, MA Taubman et al. 2014;\13\
emergency department Akosa Antwi et al.
use, with some 2015;\14\ Miller
studies showing an 2012;\15\ Sommers et
increase and others al. 2016 \11\
a decrease
Improved access to DCP, MA Scott et al. 2016;\16\
surgical care Loehrer et al. 2016
\17\
Chronic disease care and
outcomes
Increased rates of Medicaid Baicker et al. 2013;\4\
diagnosing chronic Wherry and Miller 2016
conditions \18\
Increased treatment Medicaid Baicker et al. 2013;\4\
for chronic Sommers et al. 2017
conditions \19\
Improved depression Medicaid Baicker et al. 2013 \4\
outcomes
No significant change Medicaid Baicker et al. 2013 \4\
in blood pressure,
cholesterol, or
glycated hemoglobin
Mixed evidence on MA, DCP Keating et al. 2013;\20\
cancer stage at time Robbins et al.
of diagnosis 2015;\21\ Loehrer et
al. 2016 \17\
Well-being and self-
reported health
Improved self- Medicaid, MA, DCP, Baicker et al. 2013;\4\
reported health in ACA Sommers et al.
most studies 2012;\22\ Van Der Wees
et al. 2013;\23\ Chua
and Sommers 2014;\6\
Sommers et al.
2015;\24\ Simon et al.
2017;\10\ Sommers et
al. 2017 \19\
Some ACA-specific Medicaid, ACA Courtemanche et al.
studies have shown 2017;\25\ Miller and
limited or Wherry 2017 \26\
nonsignificant
changes
Mortality
Conflicting Private insurance Kronick 2009;\27\ Wilper
observational et al. 2009 \28\
studies on whether
lack of insurance is
an independent
predictor of
mortality
Highly imprecise Medicaid Finkelstein et al. 2012
estimates in \8\
randomized trial,
unable to rule out
large mortality
increases or
decreases
Significant Medicaid, MA Sommers et al. 2012;\22\
reductions in Sommers et al. 2014;\9\
mortality in quasi- Sommers 2017 \29\
experimental
analyses,
particularly for
health care-amenable
causes of death
------------------------------------------------------------------------
* ``Medicaid'' includes pre-ACA expansions of Medicaid in selected
states and the ACA's 2014 Medicaid expansion. ACA denotes Affordable
Care Act (specifically applies here to the 2014 coverage expansions
including Medicaid and subsidized market place coverage), DCP
dependent-coverage provision (the ACA policy enacted in 2010 that
allows young adults to remain on their parents' plan until the age of
26 years), and MA Massachusetts statewide health care reform (enacted
2006).
ACCESS TO CARE AND UTILIZATION
For coverage to improve health, insurance must improve people's care,
not just change how it's paid for. Several observational studies have
found that the ACA's coverage expansion was associated with higher
rates of having a usual source of care and being able to afford needed
care,\32\, \33\ factors typically associated with better
health outcomes.\34\ Stronger experimental and quasi-experimental
evidence shows that coverage expansions similarly lead to greater
access to primary care,\11\, \24\ more ambulatory care
visits,\8\ increased use of prescription medications,\4\,
\12\ and better medication adherence.\11\
There is also strong evidence that coverage expansion increases access
to preventive services, which can directly maintain or improve health.
Studies of Massachusetts' health care reform \9\ and the ACA's Medicaid
expansion found higher rates of preventive health care visits,\1\ and
although the utility of the ``annual exam'' is uncertain, such visits
may facilitate more specific evidence-based screening. For instance,
the ACA Medicaid expansion has led to significant increases in testing
for diabetes,\11\ hypercholesterolemia,\18\ and HIV,\10\ and the Oregon
study revealed a 15-
percentage-point increase in the rate of cholesterol screening and 15-
to 30-percentage-point increases in rates of screening for cervical,
prostate, and breast cancer.\4\
The connection between health outcomes and use of other services, such
as surgery, emergency-department (ED) care, and hospitalizations, tends
to be more complicated. Much of this utilization serves critical health
needs, though some may represent low-value care or reflect poor
outpatient care. Thus, it is perhaps not surprising that the evidence
on the effects of coverage on ED use and hospitalizations is mixed.\35\
Both types of utilization went up in the Oregon study,\8\,
\13\ whereas studies of other coverage expansions found reductions in
ED use,\11\, \14\, \15\ and changes in hospital
use have not been significant in several ACA studies\11\,
\26\--though these studies may not have had an adequate sample size to
examine this less common outcome. Meanwhile, studies of Massachusetts'
reform and the ACA's dependent-coverage provision indicate that
insurance improves access to some high-value types of surgical
care.\16\, \17\
CHRONIC DISEASE CARE AND OUTCOMES
The effects of coverage are particularly important for people with
chronic conditions, a vulnerable high-cost population. Here, the Oregon
experiment found nuanced effects. After 2 years of coverage, there were
no statistically significant changes in glycated hemoglobin, blood
pressure, or cholesterol levels.\4\ On the basis of these results, some
observers have argued that expanding Medicaid does not improve health
and is thus inadvisable.\36\ However, the study revealed significant
increases in the rate of diagnosis of diabetes that were consistent
with findings in two recent post-ACA studies \18\, \37\
along with a near-doubling of use of diabetes medications,\4\ again
consistent with more recent data on the ACA's Medicaid expansion.\12\
Glycated hemoglobin levels did not improve, but, as the authors note,
the confidence intervals are potentially consistent with these
medications' working as expected.\4\ The investigators did not detect
significant changes in diagnosis of or treatment for high cholesterol
or hypertension. One recent quasi-experimental study, however, showed
that the ACA's Medicaid expansion was associated with better blood-
pressure control among community health center patients.\38\
Meanwhile, the Oregon study found substantial improvements in
depression, one of the leading causes of disability in the United
States.\39\ It also found an increased rate of diagnosis, a borderline-
significant increase in the rate of treatment with antidepressant
medication, and a 30% relative reduction in rates of depressive
symptoms.\4\
Other studies have assessed the effects of insurance coverage on
cancer, the leading cause of death among nonelderly adults in the
United States.\40\ Though not all cancer results in chronic illness,
most cancer diagnoses necessitate a period of ongoing care, and
approximately 8 million U.S. adults under age 70 are currently living
with cancer.\41\ Beyond increases in cancer screening, health insurance
may also facilitate more timely or effective cancer care. However,
evidence on this front is mixed. A study of Massachusetts' reform did
not find any changes in breast-cancer stage at diagnosis,\20\ whereas
the ACNs dependent-coverage provision was associated with earlier-stage
diagnosis and treatment of cervical cancer among young women.\21\
Another Massachusetts study revealed an increase in rates of
potentially curative surgery for colon cancer among low-income patients
after coverage expansion, with fewer patients waiting until the
emergency stage for treatment.\17\
Coverage implications for many other illnesses such as asthma, kidney
disease, and heart failure require additional research. Studies do show
that for persons reporting any chronic condition, gaining coverage
increases access to regular care for those conditions.\19\,
\30\ Overall, the picture for managing chronic physical conditions is
thus not straightforward, with coverage effects potentially varying
among diseases, populations, and delivery systems.
WELL-BEING AND SELF-REPORTED HEALTH
Although the evidence on outcomes for some conditions varies, evidence
from multiple studies indicates that coverage substantially improves
patients' perceptions of their health. At 1 year, the Oregon study
found a 25% increase in the likelihood of patients reporting ``good,
very good, or excellent'' health, and more days in good physical and
mental health.\8\ Evidence from quasi-experimental studies indicates
that self-reported health and functional status improved after
Massachusetts' reform \23\ and after several pre-ACA state Medicaid
expansions,\22\ and that self-
reported physical and mental health improved after the ACA's dependent-
coverage provision went into effect.\6\
Recent studies of the ACA's 2014 coverage expansion provide more mixed
evidence. Multiple analyses have found improved self-reported health
after the ACA's coverage expansion, either in broad national trends
\24\ or Medicaid expansion studies,\10\, \11\ whereas one
found significant changes only for select subpopulations \25\ and
another not at all.\26\ Larger coverage gains have generally been
associated with more consistent findings of improved self-reported
health.\19\
Does self-reported health even matter? It squarely fits within the
World Health Organization's definition of health as ``a state of
complete physical, mental, and social well-being,'' and improved
subjective well-being (i.e., feeling better) is also a primary goal for
much of the medical care delivered by health care professionals. In
addition, self-reported health is a validated measure of the risk of
death. People who describe their health as poor have mortality rates 2
to 10 times as high as those who report being in the healthiest
category.\42\, \43\
MORTALITY
Perhaps no research question better encapsulates this policy debate
than, ``Does coverage save lives?'' Beginning with the Institute of
Medicine's 2002 report Care Without Coverage, some analyses have
suggested that lack of insurance causes tens of thousands of deaths
each year in the United States.\44\ Subsequent observational studies
had conflicting findings. One concluded that lacking coverage was a
strong independent risk factor for death,\28\ whereas another found
that coverage was only a proxy for risk factors such as socioeconomic
status and health-related behaviors.\27\ More recently, several studies
have been conducted with stronger research designs better suited to
answering this question.
The Oregon study assessed mortality but was limited by the infrequency
of deaths in the sample. The estimated 1-year mortality change was a
nonsignificant 16% reduction, but with a confidence interval of -82% to
+50%, meaning that the study could not rule out large reductions--or
increases--in mortality. As the authors note, the study sample and
duration were not well suited to evaluating mortality.
Several quasi-experimental studies using population-level data and
longer follow-up offer more precise estimates of coverage's effect on
mortality. One study compared three states implementing large Medicaid
expansions in the early 2000s to neighboring states that didn't expand
Medicaid, finding a significant 6% decrease in mortality over 5 years
of follow-up.\22\ A subsequent analysis showed the largest decreases
were for deaths from ``health-care-amenable'' conditions such as heart
disease, infections, and cancer, which are more plausibly affected by
access to medical care.\29\ Meanwhile, a study of Massachusetts' 2006
reform found significant reductions in all-cause mortality and health-
care-amenable mortality as compared with mortality in demographically
similar counties nationally, particularly those with lower pre-
expansion rates of insurance coverage.\9\ Overall, the study identified
a ``number needed to treat'' of 830 adults gaining coverage to prevent
one death a year. The comparable estimate in a more recent analysis of
Medicaid's mortality effects was one life saved for every 239 to 316
adults gaining coverage.\29\
How can one reconcile these mortality findings with the nonsignificant
cardiovascular and diabetes findings in the Oregon study? Research
design could account for the difference: the Oregon experiment was a
randomized trial and the quasi-
experimental studies were not, so the latter are susceptible to
unmeasured confounding despite attempts to rule out alternative
explanations, such as economic factors, demographic shifts, and secular
trends in medical technology. But--as coauthors of several of these
articles--we believe that other explanations better account for this
pattern of results.
First, mortality is a composite outcome of many conditions and factors.
Hypertension, dyslipidemia, and elevated glycated hemoglobin levels are
important clinical measures but do not capture numerous other causes of
increased risk of death. Second, the studies vary substantially in
their timing and sample sizes. The Massachusetts and Medicaid mortality
studies examined hundreds of thousands of people gaining coverage over
4 to 5 years of follow-up, as compared with roughly 10,000 Oregonians
gaining coverage and being assessed after less than 2 years. It may
take years for important effects of insurance coverage--such as
increased use of primary and preventive care, or treatment for life-
threatening conditions such as cancer, HIV-AIDS, or liver or kidney
disease--to manifest in reduced mortality, given that mortality changes
in the other studies increased over time.\9\, \22\
Third, the effects on self-reported health--so clearly seen in the
Oregon study and other research--are themselves predictive of reduced
mortality over a 5- to 10-year period.\42\, \43\ Studies
suggest that a 25% reduction in self-reported poor health could
plausibly cut mortality rates in half (or further) for the sickest
members of society, who have disproportionately high rates of death.
Finally, the links among mental health, financial stress, and physical
health are numerous,\45\ suggesting additional pathways for coverage to
produce long-term health effects.
DIFFERENT TYPES OF COVERAGE
In light of recent evidence on the benefits of health insurance
coverage, some ACA critics have argued that private insurance is
beneficial but Medicaid is ineffective or even harmful.\46\ Is there
evidence for this view? There is a greater body of rigorous evidence on
Medicaid's effects--from studies of pre-ACA expansions, from the Oregon
study, and from analyses of the ACA itself--than there is on the
effects of private coverage. The latter includes studies of the ACA's
dependent-coverage provision, which expanded only private insurance,
and of Massachusetts' reform, which featured a combination of Medicaid
expansion, subsidies for private insurance through Medicaid managed
care insurers, and some in crease in employer coverage. But there is no
large quasi-experimental or randomized trial demonstrating unique
health benefits of private insurance. One head-to-head quasi-
experimental study of Medicaid versus private insurance, based on
Arkansas's decision to use ACA dollars to buy private coverage for low-
income adults, found minimal differences.\11\, \19\ Overall,
the evidence indicates that having health insurance is quite
beneficial, but from patients' perspectives it does not seem to matter
much whether it is public or private.\47\ Further research is needed to
assess the relative effects of various insurance providers and plan
designs.
Finally, though it is outside the focus of our discussion, there is
also quasi-experimental evidence that Medicare improves self-reported
health \48\ and reduces in-
hospital mortality among the elderly,\49\ though a study of older data
from Medicare's 1965 implementation did not find a survival
benefit.\50\ However, since universal coverage by Medicare for elderly
Americans is well entrenched, both the policy debate and opportunities
for future research on this front are much more limited.
IMPLICATIONS AND CONCLUSIONS
One question experts are commonly asked is how the ACA--or its repeal--
will affect health and mortality. The body of evidence summarized here
indicates that coverage expansions significantly increase patients'
access to care and use of preventive care, primary care, chronic
illness treatment, medications, and surgery. These increases appear to
produce significant, multi-faceted, and nuanced benefits to health.
Some benefits may manifest in earlier detection of disease, some in
better medication adherence and management of chronic conditions, and
some in the psychological well-being born of knowing one can afford
care when one gets sick. Such modest but cumulative changes--which one
of us has called ``the heroism of incremental care'' \51\--may not
occur for everyone and may not happen quickly. But the evidence
suggests that they do occur, and that some of these changes will
ultimately help tens of thousands of people live longer lives.
Conversely, the data suggest that policies that reduce coverage will
produce significant harms to health, particularly among people with
lower incomes and chronic conditions.
Do these findings apply to the ACA? Drawing on evidence from recent
coverage expansions is, in our view, the most reasonable way to
estimate future effects of policy, but this sort of extrapolation is
not an exact science. The ACA shares many features with prior
expansions, in particular the Massachusetts reform on which it was
modeled. But it is a complex law implemented in a highly contentious
and uncertain policy environment, and its effects may have been limited
by policies in some states that reduced take-up.\52\ Congress's partial
defunding of the provisions for stabilizing the ACA's insurance
marketplaces,\53\ and plan offerings with high patient cost sharing.
Furthermore, every state's Medicaid program has unique features, which
makes direct comparisons difficult. Finally, coverage expansions and
contractions will not necessarily produce mirror-image effects. For
these reasons, no study can offer a precise prediction for the current
policy debate. But our assessment, in short, is that these studies
provide the best evidence we have for projecting the impact of the ACA
or its repeal.
The many benefits of coverage, though, come at a real cost. Given the
increases in most types of utilization, expanding coverage leads to an
increase in societal resources devoted to health care.\8\ There are key
policy questions about how to control costs, how much redistribution
across socioeconomic groups is optimal, and how trade-offs among
federal, state, local, and private spending should be managed. In none
of these scenarios, however, is there evidence that covering more
people in the United States will ultimately save society money.
Are the benefits of publicly subsidized coverage worth the cost? An
analysis of mortality changes after Medicaid expansion suggests that
expanding Medicaid saves lives at a societal cost of $327,000 to
$867,000 per life saved.\29\ By comparison, other public policies that
reduce mortality have been found to average $7.6 million per life
saved, suggesting that expanding health insurance is a more cost-
effective investment than many others we currently make in areas such
as workplace safety and environmental protections.\29\, \54\
Factoring in enhanced well-being, mental health, and other outcomes
would only further improve the cost-benefit ratio. But ultimately,
policymakers and other stakeholders must decide how much they value
these improvements in health, relative to other uses of public
resources--from spending them on education and other social services to
reducing taxes.
There remain many unanswered questions about U.S. health insurance
policy, including how to best structure coverage to maximize health and
value and how much public spending we want to devote to subsidizing
coverage for people who cannot afford it. But whether enrollees benefit
from that coverage is not one of the unanswered questions. Insurance
coverage increases access to care and improves a wide range of health
outcomes. Arguing that health insurance coverage doesn't improve health
is simply inconsistent with the evidence.
Disclosure forms provided by the authors are available at https://
www.nejm.
org/.
From the Department of Health Policy and Management, Harvard T.H. Chan
School of Public Health (B.D.S., A.A.G., K.B.), and the Departments of
Medicine (B.D.S.) and Surgery (A.A.G.), Harvard Medical School and
Brigham and Women's Hospital-all in Boston.
This article was published on June 21, 2017, at https://www.nejm.org/.
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Intern Med 2014;160:585-93.
10. Simon K, Soni A, Cawley J. The impact of health insurance on
preventive care and health behaviors: evidence from the first two years
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11. Sommers BD, Blendon RJ, Orav EJ, Epstein AM. Changes in utilization
and health among low-income adults after Medicaid expansion or expanded
private insurance. JAMA Intern Med 2016;176:1501-9.
12. Ghosh A, Simon K, Sommers BD. The effect of state Medicaid
expansions on prescription drug use: evidence from the Affordable Care
Act. Cambridge, MA: National Bureau of Economic Research, 2017.
13. Taubman SL, Allen HL, Wright BJ, Bakker K, Finkelstein AN. Medicaid
increases emergency-department use: evidence from Oregon's Health
Insurance Experiment. Science 2014;343:263-8.
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Affordable Care Act's Dependent Coverage Provision. Ann Emerg Med
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15. Miller S. The effect of insurance on emergency room visits: an
analysis of the 2006 Massachusetts health reform. J Public Econ
2012;96:893-908.
16. Scott JW, Rose JA, Tsai TC, et al. Impact of ACA insurance coverage
expansion on perforated appendix rates among young adults. Med Care
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17. Loehrer AP, Song Z, Haynes AB, Chang DC, Hutter MM, Mullen JT.
Impact of health insurance expansion on the treatment of colorectal
cancer. J Clin Oncol 2016;34:4110-5.
18. Wherry LR, Miller S. Early coverage, access, utilization, and
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803.
19. Sommers BD, Maylone B, Blendon RJ, Orav EJ, Epstein AM. Three-year
impacts of the Affordable Care Act: improved medical care and health
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20. Keating NL, Kouri EM, He Y, West DW, Winer EP. Effect of
Massachusetts health insurance reform on mammography use and breast
cancer stage at diagnosis. Cancer 2013;119:250-8.
21. Robbins AS, Han X, Ward EM, Simard EP, Zheng Z, Jemal A.
Association between the Affordable Care Act dependent coverage
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22. Sommers BD, Baicker K, Epstein AM. Mortality and access to care
among adults after state Medicaid expansions. N Engl J Med
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23. Van Der Wees PJ, Zaslavsky AM, Ayanian JZ. Improvements in health
status after Massachusetts health care reform. Milbank Q 2013;91:663-
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24. Sommers BD, Gunja MZ, Finegold K, Musco T. Changes in self-reported
insurance coverage, access to care, and health under the Affordable
Care Act. JAMA 2015;314:366-74.
25. Courtemanche C, Marton J, Ukert B, Yelowitz A, Zapata D. Early
effects of the Affordable Care Act on health care access, risky health
behaviors, and self-assessed health. Cambridge, MA: National Bureau of
Economic Research, 2017.
26. Miller S, Wherry LR. Health and access to care during the first 2
years of the ACA Medicaid expansions. N Engl Med 2017;376:947-56.
27. Kronick R. Health insurance coverage and mortality revisited.
Health Serv Res 2009;44:1211-31.
28. Wilper AP, Woolhandler S, Lasser KE, McCormick D, Bor DH,
Himmelstein DU. Health insurance and mortality in U.S. adults. Am J
Public Health 2009;
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29. Sommers BD. State Medicaid expansions and mortality, revisited: a
cost-benefit analysis. Am J Health Econ 2017 May 17th (Epub ahead of
print).
30. Torres H, Poorman E, Tadepalli U, et al. Coverage and access for
Americans with chronic disease under the Affordable Care Act: a quasi-
experimental study. Ann Intern Med 2017;166:472-9.
31. Allen H, Baicker K, Finkelstein A, Taubman S, Wright BJ. What the
Oregon Health Study can tell us about expanding Medicaid. Health Aff
(Millwood) 2010;29:1498-506.
32. Shartzer A, Long SK, Anderson N. Access to care and affordability
have improved following Affordable Care Act implementation; problems
remain. Health Aff (Millwood) 2016;35:161-8.
33. Collins SR, Gunja M, Doty MM, Beutel S. Americans' experiences with
ACA Marketplace and Medicaid coverage: access to care and satisfaction.
New York: The Commonwealth Fund, 2016.
34. Starfield B, Shi L, Macinko J. Contribution of primary care to
health systems and health. Milbank Q 2005;83:457-502.
35. Sommers BD, Simon K. Health insurance and emergency department
use--a complex relationship. N Engl J Med 2017;376:1708-11.
36. Cannon MF. Oregon study throws a stop sign in front of ObamaCare's
Medicaid expansion. Washington, DC: Cato Institute, 2013.
37. Kaufman HW, Chen Z, Fonseca VA, McPhaul MJ. Surge in newly
identified diabetes among Medicaid patients in 2014 within Medicaid
expansion states under the Affordable Care Act. Diabetes Care
2015;38:833-7.
38. Cole MB, Galarraga O, Wilson IB, Wright B, Trivedi AN. At federally
funded health centers, Medicaid expansion was associated with improved
quality of care. Health Aff (Millwood) 2017;36:40-8.
39. Murray CJ, Atkinson C, Bhalla K, et al. The state of U.S. health,
1990-2010: burden of diseases, injuries, and risk factors. JAMA
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40. 10 leading causes of death by age group, United States--2015.
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health status as a health measure: the predictive value of self-
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43. DeSalvo KB, Bloser N, Reynolds K, He J, Muntner P. Mortality
prediction with a single general self-rated health question: a meta-
analysis. J Gen Intern Med 2006;21:267-75.
44. Care without coverage: too little, too late. Washington, DC:
Institute of Medicine, 2002.
45. Krieger N. Epidemiology and the people's health: theory and
context. Oxford, United Kingdom: Oxford University Press, 2013.
46. Roy A. Romneycare improved health outcomes, thanks to private-
sector coverage. Forbes. May 7, 2014 (https://www.forbes.com/sites/
theapothecary/2014/05/07/romneycare-improved-health-outcomes-thanks-to-
private-sector-coverage/#6bcbd7flde55).
47. Epstein AM, Sommers BD, Kuznetsov Y, Blendon RJ. Low-income
residents in three states view Medicaid as equal to or better than
private coverage, support expansion. Health Aff (Millwood)
2014;33:2041-7.
48. McWilliams JM, Meara E, Zaslavsky AM, Ayanian JZ. Health of
previously uninsured adults after acquiring Medicare coverage. JAMA
2007;298:2886-94.
49. Card D, Dobkin C, Maestas N. Does Medicare save lives? Q J Econ
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124:597-636.
50. Finkelstein A, McKnight R. What did Medicare do? The initial impact
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incremental-care).
52. Sommers BD, Maylone B, Nguyen KH, Blendon RJ, Epstein AM. The
impact of state policies on ACA applications and enrollment among low-
income adults in Arkansas, Kentucky, and Texas. Health Aff (Millwood)
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53. Garthwaite C, Graves JA. Success and failure in the insurance
exchanges. N Engl J Med 2017;376:907-10.
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______
Family Voices
P.O. Box 37188
Albuquerque, NM 87176
202-669-5233
As a nonpartisan organization of and for families of children and youth
with special health care needs, Family Voices strongly urges Congress
to reject the Graham-
Cassidy bill. Children and youth with special health care needs include
children with physical and developmental disabilities, chronic
illnesses, brain injury, cancer, and rare diseases. Over 40 percent of
children and youth with special health care needs--over 6 million
children--rely on the Medicaid program to get the health care they
need. Often this care includes life-sustaining equipment or medications
that virtually no family could afford without help, even if they have
private insurance coverage.
By severely capping the federal contribution to Medicaid, this
legislation will significantly compromise the nation's health care
system for children in general and children with special health care
needs in particular. With much less funding for Medicaid, states will
be compelled to restrict eligibility, cut critical benefits, and/or
reduce reimbursement to providers, thus reducing access to care,
especially in rural areas. Senators wisely rejected earlier legislation
that would have capped the Medicaid program. The Graham-Cassidy bill
would be even worse than those other bills for the children (and
others) who rely on Medicaid for their health care.
This bill is also worse for those relying on private insurance. If they
vote for this bill, Senators will be doing what almost every one of
them said they would not do--end the guarantee that people with pre-
existing conditions will not face discrimination and prohibitively high
premiums. If this bill is enacted, people with the greatest need for
health care may not be able to afford the insurance to pay for it. And
if they cannot afford the insurance, they will not have access to care.
They will do without treatment they need or will incur great medical
debt trying to pay for it.
Moreover, this legislation also allow states to let insurers offer
polices that do not cover important health benefits, such as maternity
care, substance abuse treatment, and pediatric oral and vision care.
We recognize that policy makers have different philosophies about the
federal government's role in the health care system. But this system is
vast and complex; any legislation that would make extensive changes to
it, as would the Graham-Cassidy bill, should be very carefully
considered. Such legislation should be subject to multiple hearings,
analyzed by experts--including the Congressional Budget Office--
available for public comment, and debated rationally by lawmakers who
are fully informed about its impact on their constituents. This
``regular order'' has been completely bypassed with respect to the
Graham-Cassidy bill--another reason that Senators should reject it next
week.
We respectfully ask each Senator to pay heed to the scores of patient
groups, health care providers and health care experts who have warned
that this legislation will hurt millions of Americans. Most important,
we ask each Senator to listen to the pleas of their constituents whose
children have significant health care needs.
Our children are our greatest responsibility and the future of our
country. Family voices are united in their message: This legislation
will jeopardize the health of our children and the wel-being of our
families. Senators should reject the Graham-
Cassidy bill.
About Family Voices
Family Voices is a national, nonprofit, family-led organization
promoting quality health care for all children and youth, particularly
those with special health care needs. Working with family leaders and
professional partners at the local, state, regional, and national
levels since 1992, Family Voices has brought a respected family
perspective to improving health care programs and policies and ensuring
that health care systems include, listen to, and honor the voices of
families.
______
Feminist Majority
1600 Wilson Boulevard, Suite 801
Arlington, VA 22209
703-522-2214
703-522-2219 fax
Chairman Orrin Hatch
Ranking Member Ron Wyden
U.S. Senate
Committee on Finance
RE: Hearing to consider the Graham-Cassidy-Heller-Johnson proposal
Dear Chairman Hatch, Ranking Member Wyden, and Members of the
Committee:
On behalf of the Feminist Majority, a national women's rights
organization dedicated to women's equality, reproductive health, and
the empowerment of women in girls in all sectors of society, we write
in strong opposition to the Graham-Cassidy-Heller-Johnson (``Graham-
Cassidy'') proposal to repeal the Affordable Care Act (ACA), severely
cut federal funding for the Medicaid program, and change the financing
structure of Medicaid to a per capita cap or block grant system.
This plan would have a devastating impact on women's health. Not only
would it cut off access to health insurance coverage for an estimated
32 million people, the Graham-Cassidy bill would make it more
difficult, if not impossible, for many to access care, including women,
people with disabilities, seniors, and anyone with a prior medical
condition.
Medicaid
The Medicaid program provides a lifeline for millions of people,
including middle-class people who rely on Medicaid to fill healthcare
gaps, and gives families and individuals a chance to lead healthy
lives. The Graham-Cassidy bill, however, would fundamentally dismantle
this lifesaving program. The deep funding cuts to Medicaid contained in
the Graham-Cassidy proposal together with its proposed block grants and
per capita caps on federal Medicaid funds shifts enormous costs to the
states, threatens state budgets, and jeopardizes access to care.
Without the guarantee of federal funds for all Medicaid enrollees,
states will be forced to cut benefits, either by limiting covered
services, increasing cost-sharing on low-income people, or restricting
enrollment. States will also be hampered in their responses to public
health emergencies, such as the opioid crisis or an outbreak of Zika,
or to increased demand on healthcare services.
By limiting federal support for Medicaid, including by cutting the
growth rate, the Graham-Cassidy proposal puts the health and lives of
women, the elderly, and people with disabilities at risk. Two-thirds of
adult Medicaid beneficiaries are women,\1\ and Medicaid provides health
coverage to one in five women of reproductive age.\2\ Nearly one-third
of Black women, over one-quarter of Latinas, and about 20 percent of
Asian American and Pacific Islander women of reproductive age are
enrolled in the program.\3\ Medicaid covers the cost of over half of
all births in the U.S. and provides nearly 75 percent of all public
family planning funds.\4\ It also pays for more than half of all long-
term care expenditures, including nursing homes.\5\ Two-thirds of
nursing home patients are women.\6\ Medicaid allows these women, many
of whom have gone through their savings and assets, to receive the
long-term care they need. Medicaid cuts and caps, however, will
restrict access to care at all stages of women's lives, leading to
poorer health outcomes that can impact not just individual well-being
but also destabilize families and communities.
---------------------------------------------------------------------------
\1\ Julia Paradise, et al., Kaiser Family Foundation, ``Medicaid at
50,'' http://www.kff.org/report-section/medicaid-at-50-low-income-
pregnant-women-children-and-families-and-childless-adults/.
\2\ Kaiser Family Foundation, ``Medicaid's Role for Women'' (June
22, 2017), http://www.
kff.org/womens-health-policy/fact-sheet/medicaids-role-for-women/.
\3\ In Our Own Voice: National Black Women's Reproductive Justice
Agenda, et al., Fact Sheet, ``Attacks on the Affordable Care Act,
Planned Parenthood and Medicaid Are Attacks on Reproductive Justice for
Women of Color'' (September 2017), available at http://www.national
partnership.org/research-library/repro/the-house-republican-repeal-
bill-threatens-reproductive-justice-for-women-of-color.pdf.
\4\ Kaiser Family Foundation, supra note 2.
\5\ Id.
\6\ Id.
Although the proposed changes to Medicaid would have a devastating
impact on all aspects of women's health, the proposed funding ban to
Planned Parenthood is particularly harmful. The Graham-Cassidy plan
would prohibit Planned Parenthood from receiving any Medicaid funding
for one year for any service, including family planning, cancer
screenings, and testing for sexually transmitted infections. Barring
Planned Parenthood from receiving federal Medicaid reimbursements
jeopardizes access to these basic healthcare services for millions of
low income women and young people. More than half of Planned
Parenthood's patients rely on Medicaid for care, and 56 percent of
Planned Parenthood health centers are in rural or medically underserved
---------------------------------------------------------------------------
areas.
Medicaid also allows people with disabilities to receive critically
needed care, whether medications, therapy, or community-based or in-
home services. This care frees people to pursue jobs or an education,
or simply allows them to live with their families instead of inside
institutions. Roughly 40 percent of Medicaid spending benefits people
with disabilities. \7\ Medicaid covers 60 percent of children with
disabilities, and 40 percent of non-elderly adults with
disabilities.\8\ Medicaid also provides some economic security for
caregivers, many of whom are women, who would otherwise be unable to
meet the needs of their loved ones while also meeting basic needs for
themselves or other family members.
---------------------------------------------------------------------------
\7\ Kaiser Family Foundation, ``Medicaid Pocket Primer'' (June 9,
2017), http://www.kff.org/medicaid/fact-sheet/medicaid-pocket-primer/.
\8\ Id.
The Graham-Cassidy proposal would also eliminate both federal funding
for the Medicaid expansion--which has allowed over 10 million people to
gain coverage \9\ including an estimated 3.9 million women \10\--as
well as federal premium tax credits and cost-sharing subsidies.
Instead, starting in 2020, the federal government would create new,
temporary federal block grants to the states, which are estimated to
amount to over $215 billion in revenue loss.\11\ In addition, the
Medicaid Directors of all 50 states have expressed deep concern about
these block grants, warning that the vast majority of states would not
be prepared to operationalize them in 2020, leaving the fate of
millions of people uncertain.\12\ Even more alarming, the block grants
would expire in 2026, without any guarantee of renewal, inserting even
more uncertainty into state budgets and forcing millions of people to
lose access to care.
---------------------------------------------------------------------------
\9\ Kaiser Family Foundation, ``Medicaid Expansion Enrollment FY
2016,'' http://kaiserf.am/2sPNGq6.
\10\ National Women's Law Center, ``ACA Repeal: What's at Stake for
Women's Medicaid Coverage'' (February 13, 2017), https://nwlc.org/
resources/aca-repeal-whats-at-stake-for-womens-medicaid-coverage/.
\11\ Avalere, Press Release, ``Graham-Cassidy-Heller-Johnson Bill
Would Reduce Federal Funding to States by $215 Billion'' (September 20,
2017), http://avalere.com/expertise/life-sciences/insights/graham-
cassidy-heller-johnson-bill-would-reduce-federal-funding-to-sta.
\12\ National Association of Medicaid Directors, Press Release,
``NAMD Statement on Graham-Cassidy'' (September 22, 2017), http://
medicaiddirectors.org/wp-content/uploads/2017/09/NAMD-Statement-on-
Graham-Cassidy9_22_17.pdf/.
Medicaid is the largest insurer in the nation, serving around 70
million people each year.\13\ The Graham-Cassidy proposal seeks to
dramatically cut and fundamentally change the program without a full
score from the Congressional Budget Office, without adequate hearings,
and without full and robust deliberation that includes a wide variety
of stakeholders examining the effect of program changes on the
healthcare system, on U.S. workers, and on state economies.\14\
Medicaid creates and supports millions of jobs in the U.S. and is
critical to state economies. Cutting Medicaid will undoubtedly lead to
a loss of jobs and may disproportionately impact women workers who make
up the majority of certain healthcare workers, including 80 percent of
ambulatory health care employees, 76 percent of hospital employees, and
80 percent of nursing home and residential care facility employees,
among other jobs.\15\
---------------------------------------------------------------------------
\13\ Kaiser Family Foundation, supra note 7.
\14\ The Commonwealth Fund, ``Repealing Federal Health Reform:
Economic and Employment Consequences for States'' (January 2017),
http://www.commonwealthfund.org/publications/issue-briefs/2017/jan/
repealing-federal-health-reform.
\15\ National Women's Law Center, ``Medicaid Is Vital for Women's
Jobs in Every Community'' (June 26, 2017), https://nwlc.org/resources/
medicaid-is-vital-for-womens-jobs-in-every-community/.
Time and time again, including during the previous attempts to pass ACA
repeal bills this summer, the public has rejected efforts to decimate
the Medicaid program. The Senate should abandon this effort and instead
work to protect the coverage gains made by the Affordable Care Act.
Other Aspects of ACA Repeal
In addition to the proposed changes to Medicaid, the Graham-Cassidy
bill proposes to repeal the ACA premium tax credits and cost-sharing
subsidies as well as the individual mandate. The bill would also allow
states to waive important consumer protections, such as the prohibition
on charging people with pre-existing conditions more for coverage and
the guarantee of coverage for ten categories of essential health
benefits. These provisions would put health insurance coverage out of
reach for millions, cause premiums and other costs to sky rocket, and
deny care to those in need.
By eliminating the premium tax credits and cost-sharing subsidies, the
Graham-Cassidy plan would jeopardize coverage for the over 12 million
people who enrolled in marketplace plans during the 2017 open
enrollment period.\16\ Of those who enrolled through HealthCare.gov, 54
percent were women and girls.\17\ Nationwide, 83 percent of those who
enrolled in a marketplace plan received a premium tax credit, and more
than half qualified for cost-sharing reductions.\18\ As discussed
above, the block granting of ACA federal financial assistance to the
states would be inadequate to meet the need. Further, there is no
requirement that states spend the block grant funds to help low- and
middle-income people obtain coverage, and the block grants themselves
would expire in 2026. As a result, millions of people, many of whom
accessed coverage for the first time, would lose coverage.
---------------------------------------------------------------------------
\16\ Centers for Medicare and Medicaid Services, ``Health Insurance
Marketplaces 2017 Open Enrollment Period Final Enrollment Report:
November 1, 2016-January 31, 2017'' (March 15, 2017), https://
www.ems.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2017-Fact-Sheet-
items/2017-03-15.html.
\17\ Id.
\18\ Id.
Even as the Graham-Cassidy bill would eliminate financial assistance
for marketplace enrollees, it would also cause the cost of those plans
to rise. By ending the premium tax credits and cost sharing reductions,
the Graham-Cassidy proposal would introduce a new layer of government-
created uncertainty into the private insurance market, destabilizing
the market and causing insurers to raise their rates. In addition, like
all of the ACA repeal bills that preceded it and failed, the Graham-
Cassidy plan ends the individual mandate, which could cause younger and
healthier people to leave the marketplace, raising the cost of
insurance for older adults and those with medical conditions. According
to estimates, under the Graham-Cassidy plan, premiums would rise by 20
percent in the first year alone.\19\
---------------------------------------------------------------------------
\19\ Center on Budget and Policy Priorities, ``Like Other ACA
Repeal Bills, Cassidy-Graham Plan Would Add Millions to Uninsured,
Destabilize Individual Market'' (September 20, 2017), https://
www.cbpp.org/research/health/like-other-aca-repeaI-bills-cassidy-
graham-plan-would-add-millions-to-uninsured.
Individuals with pre-existing conditions, however, would experience the
greatest cost increases because the Graham-Cassidy proposal would also
allow states to waive the protections that prohibit insurance companies
from charging individuals with pre-existing conditions more than so-
called ``healthier'' people. For women, this may mean being charged
more for having experienced a pregnancy, childbirth, an eating
disorder, depression, lupus, or breast cancer, or having received
medical treatment related to sexual or intimate partner violence.
Premium surcharges could range from $142,650 per year for metastatic
cancer to $17,320 for a pregnancy.\20\ These surcharges would price
many families and individuals out of the market. By definition, these
are people--new mothers, cancer survivors, children with medical
conditions, etc.--who most need access to healthcare.
---------------------------------------------------------------------------
\20\ Sam Berger and Emily Gee, Center for American Progress,
``Latest ACA Repeal Plan Would Explode Premiums for People With Pre-
Existing Conditions'' (April 20, 2017), https://
www.americanprogress.org/issues/healthcare/news/2017/04/20/430858/
latest-aca-repeal-plan-explode-premiums-people-pre-existing-
conditions/.
For those who can pay increasing costs, the Graham-Cassidy bill may
force them to pay more for less. Currently, insurance companies are
required to cover 10 categories of essential health benefits (EHBs),
such as emergency care, hospitalization, laboratory services, pediatric
care, and more. The Graham-Cassidy proposal, however, would allow
states to waive coverage of EHBs. States could eliminate any or all of
these benefits, including maternity care, or allow insurers to
determine the scope of coverage. As a result, people who are able to
purchase health insurance would face substantial increases in their
out-of-pocket costs for care because their insurance plan would no
longer cover the care they need. In particular, people who rely on
expensive prescription drugs, mental health services, or substance
abuse treatment could see large increases in their healthcare spending
---------------------------------------------------------------------------
or would be forced to stop receiving those services all together.
The loss of maternity care as a covered essential health benefit would
be particularly burdensome for women and their families. Prior to the
ACA, only 18 states required nongroup health insurance plans to cover
maternity care.\21\ As a result, only 12 percent of individual
insurance plans nationwide offered maternity coverage.\22\ It is
expected that states that did not previously require maternity benefits
would stop guaranteeing coverage for those services. In these states,
women who want maternity coverage would have to purchase a rider at a
cost of more than $1,000 per month, a cost that many women simply
cannot afford.\23\ Under these circumstances, having a baby could mean
financial ruin. The average cost of childbirth in the United States
ranges from around $32,000 for a vaginal birth and $51,000 for a
cesarean birth.\24\
---------------------------------------------------------------------------
\21\ Kaiser Family Foundation, ``Pre-ACA State Maternity Coverage
Mandates: Individual and Small Group Markets,'' https://www.kff.org/
state-category/health-insurance-managed-care/pre-aca-state-mandated-
health-insurance-benefits/.
\22\ National Women's Law Center, ``The Many Ways the American
Health Care Act Would Jeopardize Women's Health and Economic Security''
(May 24, 2017), https://nwlc.org/resources/the-many-ways-the-american-
health-care-act-would-jeopardize-womens-health-and-economic-security/.
\23\ Congressional Budget Office, ``Cost Estimate: H.R. 1628, the
American Health Care Act of 2017 as passed by the House of
Representatives on May 4, 2017'' at 26 (May 24, 2017), https://
www.cbo.gov/system/files/115th-congress-2017-2018/costestimate/
hr1628aspassed.pdf.
\24\ Truven Health Analytics, ``The Cost of Having a Baby in the
United States'' 6 (January 2013), http://
transform.childbirthconnection.org/wp-content/uploads/2013/01/Cost-of-
Having-a-Baby1.pdf.
Denial of maternity coverage is also dangerous and endangers women's
lives. Pregnancy carries considerable health risks, including anemia,
gestational diabetes, depression, infection, and high blood pressure,
which can lead to hypertension or preeclampsia. These conditions, if
untreated, can lead to serious complications, including preterm
delivery, low- or high-birth weight babies, and infant or maternal
---------------------------------------------------------------------------
death.
Coupling the denial of maternity coverage with the elimination of other
essential health benefits--like coverage for mental health and
substance abuse services or chronic disease management--increases the
likelihood of maternal and child death. Many maternal deaths are the
result of pre-existing health conditions like cardiovascular disease,
obesity, and substance use. If coverage for treating those underlying
conditions were cut, fewer women would be able to access care to keep
themselves and their children healthy. This is especially concerning
since the United States has the highest level of maternal death in the
developed world.\25\ Maternal death rates are particularly high among
Black women who are more likely, as a group, to experience additional
health disparities.\26\ In addition, the Graham-
Cassidy proposal would increase restrictions on abortion coverage, a
policy that undermines healthy motherhood and endangers women's health
by putting healthcare out of reach.
---------------------------------------------------------------------------
\25\ Nina Martin and Renee Montagne, ``U.S. Has the Worst Rate of
Maternal Deaths in the Developed World,'' NPR (May 12, 2017), http://
www.npr.org/2017/O5/12/528098789/u-s-has-the-worst-rate-of-maternal-
deaths-in-the-developed-world.
\26\ Centers for Disease Control and Prevention, ``Pregnancy
Mortality Surveillance System'' (June 29, 2017), https://www.cdc.gov/
reproductivehealth/maternalinfanthealth/pmss.html.
The Graham-Cassidy bill would also allow states to re-impose annual and
lifetime caps on coverage, a practice that the ACA had curbed.
Prohibiting caps on coverage ensures that families and individuals with
serious health concerns can access benefits when they need them the
most. Imposing caps is tantamount to imposing a cutoff date on
---------------------------------------------------------------------------
critically-needed care, threatening the lives of the most vulnerable.
Increasing healthcare costs would mean less financial stability for
families, too many of whom are already struggling to get by. The family
forced to pay higher premiums because of a pre-existing condition may
be forced to choose between healthcare or food, healthcare or their
child's education, healthcare or the rent. Adult children may find
themselves financially stretched to pay for an elderly parent's care
when they can no longer rely on Medicaid to help pay the cost of
nursing home care. Skyrocketing out-of-pocket costs as well as the loss
of coverage all together could lead families into bankruptcy. In fact,
a recent study of bankruptcy filings found that expanded access to
insurance coverage under the ACA helped drive down personal bankruptcy
filings.\27\ The Senate should not lead the country backward.
---------------------------------------------------------------------------
\27\ Allen St. John, ``How the Affordable Care Act Drove Down
Personal Bankruptcy,'' Consumer Reports (May 2, 2017), https://
www.consumerreports.org/personal-bankruptcy/how-the-aca-drove-down-
personal-bankruptcy/.
For the reasons discussed above, the Feminist Majority strongly opposes
the
Graham-Cassidy bill, and we urge the Senate to abandon this effort, as
well as all efforts to repeal the ACA and dismantle or defund the
Medicaid program. In addition, the Feminist Majority has grave grave
concerns about the lack of transparency surrounding the development of
this legislation, as well as previous legislation to repeal the ACA and
restructure Medicaid. It should be noted that this one hearing, with
its cursory attempt to gather public input without reasonable notice,
is not an adequate replacement for rigorous debate and deliberation of
a proposal to reshape the U.S. healthcare system. We encourage the
Senate to return to regular order and work in a bipartisan fashion to
---------------------------------------------------------------------------
strengthen the ACA and increase access to healthcare for all.
Sincerely,
Eleanor Smeal Gaylynn Burroughs
President Policy Director
______
Letter Submitted by Sarah Fox, Ph.D.
U.S. Senate
Committee on Finance
Dirksen Senate Office Bldg.
Washington, DC 20510-6200
Re: Hearing to consider the Graham-Cassidy-Heller-Johnson proposal,
Monday, September 25, 2017
Senator Hatch, Republican members of the Senate Finance Committee, and
future historians:
I am writing to share my perspectives with regard to the Graham-
Cassidy-Heller-Johnson bill, as well as all the other Republican
repeal-and-replace bills to date. Although I am addressing this letter
to the entire Finance Committee, I am really addressing just the
Republican members. I have no quarrel with the Democrats, who have
fought valiantly for access to affordable healthcare for all Americans.
They, and Senator McCain, are apparently the heroes of the day.
I also write this letter to future historians, in the hope that they
find this letter buried among thousands in the records of this Senate
hearing. Our government is in crisis, and many of us fear it cannot
survive until January 2021. We hope it does. But if it does not, we
want historians to have good records for our nation's post-mortem, so
perhaps history will not repeat itself.
My life partner has cancer--Stage IIIb melanoma. Her Obamacare
insurance (through the individual marketplace) has been indispensable
in her fight, and you want to take this all-important safety net away
from her to please the billionaire oligarchs who fund your campaigns.
As you can well imagine, we have both become highly involved in the
fight to save the ACA, because her life potentially depends on it.
Unlike you wealthy politicians, we cannot afford to pay, out of pocket,
for the sorts of drugs necessary to treat a Stage IV recurrence--like
Keytruda or Opdivo, at $150,000 for a round of treatment. So in
addition to fighting the cancer, we now have to fight the government.
Under Graham-Cassidy, the insurance available to us would be junk.
Either it would not cover cancer in any meaningful way, or it would
have an unaffordable price (or both?). So let me be crystal clear,
senators: You have tightened a noose around my life-partner's neck, and
you are threatening to kick the chair out from under her feet. You
clearly have the power to kill her, and we are helpless to stop you.
Our annoying story is but one out of the millions you've heard over and
over.
We have spent months begging for you to spare her life, but our story
clearly does not matter to you. Her life clearly has no importance in
your universe.
This has become our full-time job--fighting you. Your ignorant
supporters call us ``snowflakes,'' ``libtards,'' and ``demwits.'' They,
and you too, accuse us of being paid activists, funded apparently by
George Soros. We receive no funding from anyone. We are backed into a
corner and fighting literally for our lives! Nobody has to PAY us for
that! Perhaps doing something without pay does not compute in the minds
of the wealthy. We know many, many equally impassioned activists with
similarly compelling stories. I have not yet met anyone funded in any
way by George Soros or anyone else. Your mockery of our movement is
insulting. But with time, you will learn to respect us.
I came into this movement with the conviction of any academic, that
knowledge and truth are power. I turned a great bulk of my time towards
researching your harmful bills, and I quickly became astonished at the
level of ignorance you and your staffers have about the legislation you
write and vote to pass. So I, along with several other ad-hoc analysts,
professional analysts and journalists, sought to educate you and inform
every-day Americans. We were quite successful in doing that. You
clearly underestimated the determination of our movement.
You are now fully aware what a horrible bill you seek to pass this
week, because we have found all your tricks. Even Jimmy Kimmel is aware
of them. You are fully aware this bill would strip at least 32 million
Americans of their healthcare insurance (and in too many cases, their
very access to health care). This is irrelevant to you. You know the
personal stories of many of those who stand to die under this
legislation, and you lie to them and insult them to their faces. And
you do not care.
You understand that we would have junk insurance under Graham-Cassidy-
Heller-Johnson, and you do not care. You understand the junk insurance
would be unaffordable for many, including the poor and the elderly. And
you do not care. You know how many people you would be kicking off of
Medicaid, including the disabled and elderly. And you do not care. You
understand that hard-working families would increasingly face medical
bankruptcy, and you do not care. You understand that crippling tax
burdens would be shifted to the states, and you don't care. Governors,
insurance commissioners, medical associations, patient advocacy
associations, and our nation's top analysts, hailing from all political
ideologies, have overwhelmingly opposed this bill. And again, you do
not care. Most of all, your supposed bosses, The People, have spoken
with a rather loud, clear, and unified voice that WE DO NOT WANT THE
LEGISLATION YOU ARE TRYING TO PASS. And you do not care.
You care about nothing but being reelected, and you seem to think large
contributions from wealthy contributors will make that possible. In
your fantasy world, you believe slick TV ads are going to woo enough
stupid voters to put you over the line. And yet again, you
underestimate us. We are not stupid. We are ``woke.''
Just like we have educated our fellow Americans about the innumerable
faults with all of your repeal/replace bills, we will educate them
about your callous disregard for their best interests--for their very
lives. Whenever someone loses his or her insurance, we'll be there to
let them know why it happened. Whenever someone goes broke because of a
catastrophic illness in the family, we'll explain to them how it
wouldn't have happened under the ACA. Whenever someone dies for lack of
insurance, we'll let the grieving family know who to blame. We'll keep
track of how many people lose insurance, we will estimate the excess
death toll directly attributable to this bill in each and every state,
and we will hold you accountable for it. We will make you care, because
you will lose your jobs.
These healthcare battles--the first major battles of the new
administration--have plainly revealed all of you for the monsters you
are. We know without ambiguity that you are willing to sacrifice our
lives and well-being for the advancement of your careers. Shame on you
all!
I thank Senator McCain for standing up against what you are doing, even
though he may inexplicably agree with the bill. You Republicans have
abused your power. You have not approached Graham-Cassidy-Heller-
Johnson through proper channels. Your hearing on Monday is a sham. As
of Friday afternoon, you don't even know who your witnesses will be.
I'm sure it doesn't matter, because you won't care what they have to
say anyway. It says something very frightening that only one senator in
your party is willing to stand up for Democracy and demand a fair
process. Not even Senator Alexander is willing to do that, and I am
disappointed.
Aside from the election process, our government is no longer answerable
to The People. We have learned that. Except for our precious vote, we
no longer live in a viable Democracy. Our nation is in peril. We
progressives cherish our system of government, and we will fight our
hardest to win our country back. We will see you in the polls--in 2018,
2020, and 2022.
After we have taken back our country, the pendulum will swing rather
hard. If you Republicans destroy our Medicaid and health insurance
system, actually making it worse than it was before the ACA, you will
have lost me as a strong voice of moderation. I have discouraged the
Medicare-for-All movement because of the prudence of seeking the
attainable in our current political climate. But if we have to rebuild
from the very foundation of our healthcare system, I will be a
proponent for straight-up socialized medicine. That is because I have
learned one very important thing during all my work on this issue:
Healthcare is a RIGHT, not a privilege.
You have a lot to consider, senators. In all of your deliberations,
please remember that The People, whom you belittle, defraud, and
neglect, are your bosses. And we have run out of patience with you.
Sincerely,
Sarah Fox, Ph.D.
______
Friday Health Plans
700 Main Street, Suite 100
Alamosa, CO 81101
(800) 475-8466
https://www.fridayhealthplans.com/
September 22, 2017
U.S. Senate
Committee on Finance
Dirksen Senate Office Bldg.
Washington, DC 20510-6200
Re: Statement for the record submitted for September 25th hearing
titled ``Graham-Cassidy-Heller-Johnson Proposal''
Friday Health Plans is a small health insurer focused on ACA compliant
health insurance for rural Colorado. Unlike many larger insurers who
are running away from the ACA, we are investing to grow our
participation in this market to additional parts of Colorado. We are
also working proactively with additional states in need of offering
new, innovative health insurance options to their residents.
We support measures that will stabilize the individual marketplace,
lower premiums for more Americans, and improve consumer choice.
Unfortunately, the
Graham-Cassidy bill would significantly increase the uncertainty and
risk in this market. The ensuing confusion and volatility this bill
would create would also make it essentially impossible for us to expand
and invest in new markets.
Despite our deep concerns about Graham-Cassidy, it is our goal to be
constructive participants in the national dialogue on improving health
care access and quality, while lowering costs. We have many policy
recommendations that could help to achieve the goals of market
stabilization, lower premiums, and increased choice--here are some we
consider to be most important:
1. Enforce the individual mandate. Without the mandate (or a functional
equivalent), community rating and guaranteed issue are highly
impractical.
2. Commit to continued cost sharing reduction (CSR) subsidies. The
uncertainty around this funding is hurting consumers and is driving
higher premiums this year.
3. Fix risk adjustment methodologies. While we agree in principle to
compensating insurers who have higher risk populations, the current
risk adjustment formula has structural flaws that disadvantage small
carriers, rural carriers, and carriers that strive to offer affordable
premiums.
Thank you very much for affording us this opportunity to comment on the
Graham-Cassidy proposal and provide additional input on your efforts to
improve the health care system in the U.S. We stand ready to work with
you and any other members of the Finance Committee who share this
important goal.
Sincerely,
David Pinkert
President, Friday Health Plans
______
Letter Submitted by Anne Morgan Giroux
September 18, 2017
U.S. Senate
Committee on Finance
Dirksen Senate Office Bldg.
Washington, DC 20510-6200
Re: Hearing to consider the Graham-Cassidy-Heller-Johnson proposal on
September 25, 2017
Dear Senators,
My daughter is 22-years-old. She has epilepsy and a developmental
disability and depends on Medicaid to live. What a drain she is to the
system yes?
Hell no. She works 35 hours a week at 2 jobs. She rents an apartment
and lives mostly independently. She employs people to help her with the
things she cannot do on her own. She volunteers. She spends money
shopping at the mall near her apartment and eats out . . . a lot. Why
does this matter?
Because if you go through with this bill, she loses all of that. And we
lose . . . all of us.
She is able to keep her job because of her job coach, who helps train
her, and helps her stay on track at work, and work through any issues
and concerns. Medicaid pays for her job coach.
No job coach, no job.
No job, no rent money and no apartment
No job, no money to spend in our community.
No job, no employing staff to assist her.
No job, no life.
And the irony here is that she becomes MORE dependent on government
assistance. She qualifies for Social Security Insurance but hardly ever
receives this money because she is employed and makes enough money on
her own. However, she will need to take the full amount if she cannot
keep her job, thus relying more on taxpayer dollars.
She relies on Medicaid for her job coach, for her supports in her
apartment and for her prescription drugs. If you take that away, you
are taking away her life.
I know you all hate ObamaCare but for God's sake, would you please slow
down and listen. Give your bill time to be examined, researched and
testified on! This affects WAY too many people to ram it through.
You owe that to the people who elected you, including my 22-year-old
daughter, Lily, who by the way, also votes.
Sincerely,
Anne Morgan Giroux
Madison, WI
Mom to Lily
______
Guttmacher Institute
1301 Connecticut Avenue, NW, Suite 700
Washington, DC 20036
Tel 202-296-4012
Fax 202-223-5756
https://www.guttmacher.org/
Heather Boonstra
Director of Public Policy
September 25, 2017
U.S. Senate
Committee on Finance
Dirksen Senate Office Building
Washington, DC 20510-6200
Re: Hearing to consider the Graham-Cassidy-Heller-Johnson proposal,
September 25, 2017
Dear Chairman Hatch and Ranking Member Wyden:
Thank you for the opportunity to submit this statement on behalf of the
Guttmacher Institute in opposition to H.R. 1628, the Graham-Cassidy-
Heller-Johnson proposal to repeal the Affordable Care Act (ACA) and
overhaul the Medicaid program, on which a hearing is being held before
the Committee on Finance on September 25, 2017.
Through its work as a nonprofit research and policy organization
committed to advancing sexual and reproductive health and rights in the
United States and globally, the Guttmacher Institute has developed and
analyzed considerable evidence on the need for and benefits of
affordable, comprehensive health insurance coverage that people can use
to obtain high-quality reproductive health services at nearby, trusted
providers.
Many of the Institute's relevant research and policy analyses, along
with those of other experts in the field, are addressed in a series of
recent articles referenced below for your review:
Why Protecting Medicaid Means Protecting Sexual and Reproductive
Health.\1\
---------------------------------------------------------------------------
\1\ Sonfield, A., ``Why Protecting Medicaid Means Protecting Sexual
and Reproductive Health,'' Guttmacher Policy Review, 2017, 20: 39-43,
https://www.guttmacher.org/gpr/2017/03/why-protecting-medicaid-means-
protecting-sexual-and-reproductive-health.
---------------------------------------------------------------------------
How Dismantling the ACA's Marketplace Coverage Would Impact
Sexual and Reproductive Health.\2\
---------------------------------------------------------------------------
\2\ Hasstedt, K., ``How Dismantling the ACA's Marketplace Coverage
Would Impact Sexual and Reproductive Health,'' Guttmacher Policy
Review, 2017, 20: 48-52, https://www.
guttmacher.org/gpr/2017/04/how-dismantling-acas-marketplace-coverage-
would-impact-sexual-and-reproductive-health.
---------------------------------------------------------------------------
No One Benefits if Women Lose Coverage for Maternity Care.\3\
---------------------------------------------------------------------------
\3\ Sonfield, A., ``No One Benefits if Women Lose Coverage for
Maternity Care,'' Guttmacher Policy Review, 2017, 20: 78-81, https://
www.guttmacher.org/gpr/2017/06/no-one-benefits-if-women-lose-coverage-
maternity-care.
---------------------------------------------------------------------------
What Is at Stake With the Federal Contraceptive Coverage
Guarantee? \4\
---------------------------------------------------------------------------
\4\ Sonfield, A., ``What Is at Stake With the Federal Contraceptive
Coverage Guarantee?'', Guttmacher Policy Review, 2017, 20: 8-11,
https://www.guttmacher.org/gpr/2017/01/what-stake-federal-
contraceptive-coverage-guarantee.
---------------------------------------------------------------------------
Conservatives Are Using the American Health Care Act to Restrict
Private Insurance from Covering Abortion.\5\
---------------------------------------------------------------------------
\5\ Sonfield, A., ``Conservatives Are Using the American Health
Care Act to Restrict Private Insurance From Covering Abortion,'' Health
Affairs blog, March 21, 2017, https://www.
guttmacher.org/article/2017/03/conservatives-are-using-american-health-
care-act-restrict-private-insurance-covering.
---------------------------------------------------------------------------
Beyond the Rhetoric: The Real-World Impact of Attacks on Planned
Parenthood and Title X.\6\
---------------------------------------------------------------------------
\6\ Hasstedt, K., ``Beyond the Rhetoric: The Real-World Impact of
Attacks on Planned Parenthood and Title X,'' Guttmacher Policy Review,
2017, 20: 86-91, https://www.guttmacher.org/gpr/2017/08/beyond-
rhetoric-real-world-impact-attacks-planned-parenthood-and-title-x.
Collectively, this body of evidence demonstrates the severely negative
consequences the Graham-Cassidy proposal would have for reproductive
health. For these reasons, we oppose the Graham-Cassidy proposal and
urge the Senate to do the same, just as it has rejected all other
recent attempts to repeal the ACA and undermine Medicaid that would
have resulted in similar harms.
Benefits of the ACA for Reproductive Health
The major coverage provisions of the ACA went into effect at the
beginning of 2014, and have particularly benefitted the availability
and quality of insurance coverage for women of reproductive age (15-
44). Nationally, the proportion of these women who were uninsured
dropped by 36% between 2013 and 2015, after the ACA's coverage
expansions had been implemented.\7\ This change was driven by
substantial gains in both Medicaid coverage and private insurance
coverage via the ACA's marketplaces. It was especially pronounced in
states that had expanded Medicaid under the ACA, where collectively,
the proportion of women of reproductive age without coverage dropped by
45%.
---------------------------------------------------------------------------
\7\ Guttmacher Institute, ``Uninsured Rate Among Women of
Reproductive Age Has Fallen More Than One-Third Under the Affordable
Care Act,'' News in Context, November 17, 2016, https://
www.guttmacher.org/article/2016/11/uninsured-rate-among-women-
reproductive-age-has-fallen-more-one-third-under.
Moreover, the ACA established important protections specifically for
coverage of reproductive health services, and has done much to promote
---------------------------------------------------------------------------
better access to this care:
Contraception: An estimated 58 million women have benefitted
from the contraceptive coverage guarantee.\8\ Privately insured women
have experienced notable declines in out-of-pocket costs for
contraception, an impact that has become more pronounced over time.\9\
---------------------------------------------------------------------------
\8\ National Women's Law Center (NWLC), ``New Data Estimate 57.6
Million Women Have Coverage of Birth Control Without Out-of-Pocket
Costs,'' Washington, DC: NWLC, 2017, https://nwlc.org/resources/new-
data-estimate-57-6-million-women-have-coverage-of-birth-control-
without-out-of-pocket-costs/.
\9\ Sonfield, A., et al., ``Impact of the federal contraceptive
coverage guarantee on out-of-pocket payments for contraceptives: 2014
update,'' Contraception, 2015, 91(1):44-48, http://www.
contraceptionjournal.org/article/S0010-7824(14)00687-8/abstract.
Maternity care: The ACA also closed major gaps in private
insurance coverage of maternity care, by requiring plans in the small
group and individual markets to cover those services.\10\ Prior to the
ACA, 8 in 10 plans in the individual market failed to cover maternity
care at all.
---------------------------------------------------------------------------
\10\ NWLC, ``Nowhere to Turn: How the Individual Health Insurance
Market Fails Women,'' Washington, DC: NWLC, 2008, https://nwlc.org/
resources/nowhere-turn-how-individual-health-insurance-market-fails-
women/.
Access to providers: Safety-net health centers that provide
family planning services have become an increasingly valued part of the
health care system,\11\ delivering high-quality care to insured and
uninsured individuals alike.\12\ The ACA has sparked this trend,
including by requiring marketplace plans to contract with local safety-
net providers.
---------------------------------------------------------------------------
\11\ Hasstedt, K., and Rowan, A., ``Marketplace Plans' Provider
Networks Are Just Not Adequate Without Family Planning Centers,''
Guttmacher Policy Review, 2015, 18(2): 48-55, https://
www.guttmacher.org/gpr/2015/07/marketplace-plans-provider-networks-are-
just-not-adequate-without-family-planning.
\12\ Hasstedt, K., ``Through ACA Implementation, Safety-Net Family
Planning Providers Still Critical for Uninsured--and Insured--
Clients,'' 2016, https://www.guttmacher.org/article/2016/08/through-
aca-implementation-safety-net-family-planning-providers-still-critical.
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Threats of the Graham-Cassidy Proposal to Reproductive Health
In contrast to the ACA, the Graham-Cassidy proposal would have a
damaging impact on reproductive health in the United States.
The broadest consequence of the Graham-Cassidy proposal would be the
loss of comprehensive insurance coverage--including coverage for
reproductive health care--for many millions of people in this country.
The legislation would impose unprecedented and draconian caps on
federal Medicaid spending and eliminate the ACA's Medicaid expansion.
Together, these changes would fundamentally undermine a Medicaid
program that is the source of coverage for 74 million U.S. residents,
including 13 million women of reproductive age.\1\
Moreover, the Graham-Cassidy proposal would eliminate the federal ACA
marketplace, and the federal tax credits and subsidies that help make
marketplace premiums and cost sharing affordable for low-income people.
The ACA's marketplaces, tax credits and subsidies have been vital to
expanding coverage for reproductive health services.\2\
In place of the ACA's central coverage provisions, Graham-Cassidy
includes a block grant provision that would allow states to redirect
hundreds of billions of dollars in federal funding away from coverage
and care for the low-income people who most need the financial help. It
would also redistribute money in a way that is designed to punish the
states that have worked the hardest to help their residents gain
insurance coverage.\13\
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\13\ Leibenluft, J., et al., ``Like Other ACA Repeal Bills,
Cassidy-Graham Plan Would Add Millions to Uninsured, Destabilize
Individual Market,'' Washington, DC: Center on Budget and Policy
Priorities, 2017, https://www.cbpp.org/research/health/like-other-aca-
repeal-bills-cassidy-graham-plan-would-add-millions-to-uninsured.
The Congressional Budget Office (CBO) has not been given the time it
needs to analyze how the Graham Cassidy proposal would impact coverage,
premiums or out-of-pocket spending, something that should be a
prerequisite before voting on such a sweeping piece of legislation.
However, it is clear that Graham-Cassidy would devastate both Medicaid
and the individual insurance market. Previous CBO estimates of similar
legislative proposals suggest the Graham-Cassidy proposal would result
in at least 20 million people losing coverage within 10 years.\14\
Recent estimates from the Commonwealth Fund put the number of people
who stand to lose coverage at a minimum of 32 million after 2026.\15\
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\14\ Hall, K., Congressional Budget Office, letter to Senator Mike
Enzi Re: H.R. 1628, the Better Care Reconciliation Act of 2017: An
Amendment in the Nature of a Substitute [ERN17500], as posted on the
website of the Senate Committee on the Budget on July 20, 2017, https:/
/www.cbo.gov/system/files/115th-congress-2017-2018/costestimate/52941-
hr1628bcra.pdf.
\15\ Collins, S.R., ``What Are the Potential Effects of the Graham-
Cassidy ACA Repeal-and-
Replace Bill? Past Estimates Provide Some Clues,'' To The Point, The
Commonwealth Fund, http://www.commonwealthfund.org/publications/blog/
2017/sep/potential-effects-of-graham-cassidy.
In addition to resulting in extensive coverage losses, the Graham-
Cassidy proposal includes many provisions that promise to undermine
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reproductive health specifically:
Excluding Planned Parenthood from federal programs: Excluding
Planned Parenthood health centers nationwide from Medicaid would
jeopardize women's access to high-quality contraceptive and related
care, and place an incredible burden on other types of safety-net
family planning providers.\6\,}\16\
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\16\ Hasstedt, K., ``Understanding Planned Parenthood's Critical
Role in the Nation's Family Planning Safety Net,'' Guttmacher Policy
Review, 2017, 20:12-14, https://www.guttmacher.org/gpr/2017/01/
understanding-planned-parenthoods-critical-role-nations-family-
planning-safetv-net.
Undermining contraceptive coverage: The Graham-Cassidy proposal
would allow states to eliminate the protections of the ACA's preventive
services benefit for some private insurance plans. That would endanger
coverage of the full range of contraceptive methods and counseling
without additional cost-sharing, potentially forcing people to use less
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effective or desirable methods, or no method at all.\4\
Rolling back maternity coverage: The Graham-Cassidy proposal
would allow states to eliminate the requirement that marketplace and
other private health plans must cover 10 essential health benefits,
including maternity care.\3\ The proposal could also undermine other
important protections for patients, including those with preexisting
medical conditions.
Eliminating private insurance coverage of abortion: The Graham-
Cassidy proposal includes multiple provisions designed to eliminate
abortion coverage in many parts of the private insurance market.
Abortion coverage is already difficult for many women to obtain and
should be much more readily available, not restricted.\5\
In conclusion, rather than thoughtfully addressing the gaps in our
nation's systems of health insurance coverage and care, the Graham-
Cassidy proposal would wreak havoc on the nation's health coverage
programs, and most importantly, on the health and well-being of U.S.
women and their families.
Thank you for the opportunity to provide these comments.
Sincerely,
Heather Boonstra
Director of Public Policy
______
Letter Submitted by Sue Matthes Hadden, R.N.
Dear Senate Finance Committee,
The Graham-Cassidy health care bill needs a CBO score before it is
voted on. Since health care takes up over 30% of our GNP, this is
nothing to rush or take lightly.
I am a nurse who works with pediatric patients who have urology
problems. Michigan has no pediatric urologists in the upper northern
lower peninsula or upper peninsula.
For people with no insurance or who are underinsured, it is expensive
for them to bring their children to see us. But following up with us is
what is needed to ensure their kidneys are healthy and so that we can
intervene should they have decreasing kidney function. I have seen a
huge change in parents being able to keep their appointments since the
Medicaid expansion and ACA have been instituted. The
Graham-Cassidy bill will create a tragedy for our patients. This week
we had a patient who was lost to follow up for 2 years. We will now
have to remove his kidney due to this lack of follow up. This kind of
thing will sky rocket without Medicaid and adequate insurance for my
patients.
I am also very worried about my daughter who is in school getting a
degree in occupational therapy. If she is not able to get insurance
through the exchange, she will have to decrease her hours in school to
work more to afford crappy catastrophic insurance. Then if she has any
significant illness, she will have to drop out of school or declare
bankruptcy. And we know that 60% of people who declare bankruptcy do so
due to health care issues.
Please demand a CBO score of the bill before allowing a Senate vote.
This bill is a lemon.
Best regards,
Sue Hadden R.N.
______
Letter Submitted by Carolyn Holland
September 24, 2017
U.S. Senate
Committee on Finance
Dirksen Senate Office Bldg.
Washington, DC 20510-6200
Re: Hearing to consider the Graham-Cassidy-Heller-Johnson proposal,
September 25, 2017
Senator Hatch and members of the Senate Finance Committee:
I am writing to give my perspective on the Graham-Cassidy-Heller-
Johnson bill.
It is a pretense for anyone in Congress to pretend that Graham-Cassidy-
Heller-Johnson is the benign repeal of an unpopular program when it
destabilizes not only the Affordable Care Act but also Medicaid.
My father was a high school teacher who served in the Army Air Force in
WWII. On September 8th we celebrated his 94th birthday in the nursing
home that he moved into about a year and a half ago. Dad outlived his
income in that when he was 93, the unregulated escalation in medical
costs finally exceeded the meager increases in his teacher's pension
and he went on Medicaid.
My dad served his country and he served his community and he maintained
his independence for as long as he could, even well into the age-
related decline of his cognitive functioning. Needless to say, this was
preceded by a series of excruciating decisions for our family. We
simply could not provide the level of care that he gets through
Medicaid.
It is an embarrassment to this country and those like my father who
have served it that our elected representatives would consider
replacing essential federal health care programs with block grants that
leave the states with fractions of pennies on the dollar to dole out
for health care needs. Cutting programs that help citizens to obtain
medical care is just mean. You cannot make this nation greater by
impoverishing its citizens through unregulated costs, stripping them of
care, and leaving them to die.
Sincerely,
Carolyn Holland
______
Letter Submitted by Marion Holmberg
Dear Senators,
My name is Marion Holmberg, and I live in Waukesha, Wisconsin. I am the
mother of three young adults with intellectual disabilities. I am
concerned about the cuts to Medicaid that are included in this bill;
cuts to Medicaid are a direct threat to the lives and independence of
people with disabilities. All three of my children use some form of
Medicaid to help them live and work in the community.
My daughter Meara, who is 21, is a graduate of Project SEARCH and works
in one of the local schools in the kitchen. She requires regular job
coaching in order to be successful on her job. Her job coach is paid
through Wisconsin's IRIS (Include, Respect, I Self-direct), a long-term
care program funded by Medicaid dollars. She spends her afternoons
volunteering in the community supported by staff paid through IRIS.
What will happen to her life when Medicaid funding is cut? Without this
support, she sits home or worse will need to live in some type of
institutional setting.
For the sake of my children and so many others like them, I am begging
you to:
Please oppose the Graham-Cassidy bill and do not vote to move
this bill out of the Finance Committee;
Please oppose ANY cuts to Medicaid; and
Please work in a bipartisan fashion to increase access to
affordable, accessible health care and long term services and supports.
Thank you!
Marion Holmberg
______
Letter Submitted by Samir S. Jaber
U.S. Senate
Committee on Finance
Dirksen Senate Office Bldg.
Washington, DC 20510-6200
Dear Senators,
When our nation's forefathers, in the midst of their struggle to repel
their colonial masters, audaciously joined together to state that their
Independence was based on those unalienable rights that have been given
to all human beings by their Creator, they chose to highlight three of
those rights: Life, Liberty, and the pursuit of Happiness. When their
dreams were realized and codified in the Constitution of the United
States, it was no accident that the preamble stated that its purpose
was to promote the ``general welfare'' of the People.
This notion--that humanity is endowed with those unalienable rights--is
not unique to our nation. Indeed, it is a human right recognized
throughout the world. Article 3 of the Universal Declaration of Human
Rights reads that ``everyone has the right to life, liberty, and
security of person.'' Governments throughout the world recognize these
rights as an essential element of a free and prosperous society. The
world's great religions share many commonalities, but the one most
fundamental to their shared morality is their emphasis on the sanctity
of human life, and the responsibility of all people to preserve and
protect that life by any means necessary.
It is with that in mind that I write to you regarding the Graham-
Cassidy-Heller-Johnson Proposal. While I recognize that this proposal
seeks to repair a system that leaves too many of our fellow Americans
without access to healthcare, I believe its implementation will be of
disastrous consequence to millions of people in this country, and I
hope you choose to reject it.
At this point, I believe that many of you are familiar with the crisis
in our healthcare system. Millions of people in this country lack
access to affordable healthcare. Whether it is because of the rising
costs of health insurance, the lack of coverage, limited provider
options, or discriminatory insurance practices, too many people in this
country are suffering.
The Affordable Care Act (ACA), while incomplete in some respects and
flawed in others, sought to offer a remedy for those in need. Through
subsidies on the private insurance market, an increase in Medicaid
coverage, protections for young adults and people with preexisting
conditions, and requirements that health insurance policies cover
essential health benefits, the ACA presented more options for consumers
to find insurance that met their medical and financial needs.
I benefited from the ACA. While serving as a full-time student at the
University of Wisconsin Madison, I maintained a series of part-time
jobs to help pay for my housing and other costs of attendance. None of
these positions offered health insurance. Thankfully, because of the
ACA, I was able to be covered by my mother's employer-sponsored health
insurance policy until I turned 26. Thus, when I suffered a significant
knee injury a few months before my graduation, I was able to receive
treatment to repair the injury and receive physical therapy, enabling
me to walk across the stage with my peers and receive my diploma.
While I have a personal investment in the ACA, my primary reason for
writing to you is to express the fear I have for the millions of people
who will suffer if the Graham-Cassidy-Heller-Johnson proposal is signed
into law. This bill eliminates subsidies that help our fellow citizens
afford private health insurance policies. This bill will increase
health insurance premiums for the elderly and people with disabilities.
This bill will dramatically reduce the amount of money allocated for
Medicaid in the short-term--by eliminating the Medicaid Expansion--and
in the long-run--through a per capita cap--which will have a
catastrophic impact on millions of people in poverty who are dependent
on the program to keep them alive and healthy. This bill will also
enable states to eliminate protections for people with pre-existing
conditions and coverage for essential health benefits, which could
raise costs for the people most in need of medical care.
While there is a consensus from all Americans that the ACA could be
more robust--that it does not do enough to ensure that all people have
access to affordable and complete healthcare--this bill does nothing to
move the ACA towards that goal. Rather, it unravels those aspects of
the ACA that millions of Americans value and rely upon. It represents a
failure of our government to use its immense resources to help the
people it was created to serve. It represents the failure of our
representatives to uphold those principles that were the foundation of
this great nation. It represents a commitment not to the sanctity of
life, but to the desire to score a political victory, no matter the
costs to the people in need.
Healthcare should not be treated like a luxury--something that can only
be accessed by those blessed with wealth and financial stability.
Rather, healthcare is an unalienable human right. Every person will
require healthcare at one point or another in their lives. Our
government should be motivated to ensure that no one will be denied
that right because of their economic status. That should be the number
one priority of any civilized society.
By prioritizing access to affordable healthcare, you can demonstrate
fidelity to that unassailable principle that all people have the right
to life. That its sanctity is paramount. This bill stands in opposition
to this principle, and for that reason, I hope you vote against it.
Sincerely,
Sarnir S. Jaber
______
The Jewish Federations of North America (JFNA)
1720 I Street, NW
Washington, DC 20006-3736
Phone 202-785-5900
Fax 202-785-4937
https://jewishfederations.org/about-jfna/washington-dc
Mr. Chairman, Ranking Member Wyden, and Members of the Committee, the
Jewish Federations of North America (JFNA) continue to firmly oppose
Senate efforts to cap Medicaid and end the state Medicaid expansion. We
are greatly disappointed that the Graham-Cassidy amendment to H.R.
1628, the most recent effort to repeal the Affordable Care Act,
includes devastating cuts to Medicaid similar to those proposed in the
Better Care Reconciliation Act (BCRA). These cuts are the result of the
legislation's proposal to fundamentally restructure Medicaid's federal
financing commitment and roll back coverage for millions of people
covered by this vital social safety net program.
Medicaid is a lifeline for more than 70 million people, including low
income children, pregnant women, older adults, people with
disabilities, and those receiving treatment for opioid addiction
nationwide. Converting Medicaid to per capita caps ends the federal
government's long-standing commitment since Medicaid's inception to
match states' Medicaid costs. Taking this step reneges on the federal
government's promise to states and to beneficiaries that the program
will remain sufficiently flexible to adjust for economic downturns,
unexpected health care cost increases, and emergencies. We urge the
Senate not to send this legislation to the floor without first
considering it--or similar proposals in the future--through regular
order in a bipartisan process, and without thorough non-partisan
analysis of the short and long-term consequences for the nation as a
whole and for every state.
JFNA represents 148 Jewish federations and 300 network communities that
together support 15 leading academic medical centers/health systems,
100 Jewish nursing homes, 125 Jewish family and children's agencies,
and 14 group homes, providing health care for more than 1 million
Jewish and non-Jewish clients. Medicaid is a critical program for
Jewish federations throughout the country and particularly for our
communal health and long-term care partners that care for the most
vulnerable in our communities.
Restructuring and Cutting Medicaid Would Have Severe Consequences for
Vulnerable Populations and Our Network of Providers Who Care for Them
JFNA is deeply troubled by the Congressional Budget Office's (CBO)
recently announced preliminary findings that, as with BCRA, the federal
share of Medicaid would not keep pace with the real cost of health care
under the Graham-Cassidy approach.\1\ Specifically, CBO found that
federal Medicaid spending would be cut by about $1 trillion by 2026,
relative to current law, and as a result, Medicaid ``would cover
millions fewer enrollees.'' CBO attributed these spending and
enrollment cuts to the legislation's elimination of the Medicaid
expansion, its adoption of Medicaid per capita caps, and its option for
states to impose work requirements on eligible individuals.
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\1\ Congressional Budget Office, ``Preliminary Analysis of
Legislation That Would Replace Subsidies for Health Care with Block
Grants,'' September 25, 2017, https://www.cbo.gov/system/files/ll5th-
congress-2017-2018/costestimate/53126-health.pdf.
Mirroring CBO's findings about BCRA's consequences, CBO concluded that
the cuts resulting from the Graham-Cassidy per capita cap would require
states to either increase their own spending or cut their Medicaid
programs ``by cutting payments to health care providers and health
plans, eliminating optional services, restricting eligibility for
enrollment through work requirements and other changes, or (to the
extent feasible) finding more efficient methods for delivering
services.'' CBO determined that some Medicaid beneficiaries could see
---------------------------------------------------------------------------
reduced access to care or lose their Medicaid coverage entirely.
Restructuring and Cutting Medicaid Would Have Even More Serious Effects
in the Long Term
JFNA also remains gravely concerned that the Graham-Cassidy legislation
would result in even deeper cuts to Medicaid over the long term.
Particularly disturbing is the bill's provision to reduce the Medicaid
per capita cap growth rate even further in 2025, just as the baby
boomers begin to turn 80 years old--an age when they are far more
likely to need expensive and long-term care. JFNA believes that taking
this step will lead to even more significant cuts to Medicaid in 2025
and beyond, and will greatly impair Medicaid's ability to adjust for
this impending major demographic change. JFNA's concern about the
legislation's long-term effects is supported by CBO's conclusion that
BCRA, which would have reduced federal Medicaid spending through 2026
by approximately 26%, actually would have resulted in cuts of as much
as 35% in the years after 2026.
Capping Medicaid Will Not Improve Care and Will Roll Back Years of
Progress
Notably, the Graham-Cassidy legislation's effort to limit federal
spending on Medicaid by imposing per capita caps does nothing to lower
the cost of caring for Medicaid beneficiaries. Nor does it improve the
care being provided. It simply passes costs and fiscal risks to states.
The end result will be millions more without health insurance, fewer
benefits and services, and lower provider payments. These cuts will
hurt low income and vulnerable children, older adults, and people with
disabilities who have nowhere else to turn when health care providers--
such as Jewish hospitals, nursing homes, group homes, and family and
children's agencies--cannot maintain the necessary level of staffing to
provide quality care, or are forced to turn Medicaid recipients away or
even to close their doors. We believe that converting Medicaid to the
proposed per capita cap will cause irreparable harm not only to the
millions who depend on the program, but also to our large network of
providers who care for them.
JFNA believes that this legislation would roll back years of progress
in caring for vulnerable populations and promote perverse consequences,
such as:
People who desperately need Medicaid and who are currently
eligible will become uninsured and will turn increasingly to more
expensive emergency rooms for care;
States will be forced to cut back on crucial Medicaid services,
such as home and community-based services, effectively forcing people
with disabilities and older adults who are capable of living in the
community with proper home and
community-based services into nursing homes;
States will be forced to curtail their mental health and
substance use treatment services, which we know from the raging opioid
crisis are needed now more than ever;
States will be forced to reduce already low provider payment
rates, thus further decreasing the pool of providers serving Medicaid
beneficiaries and increasing waiting times for critical services; and
Health care providers and entities that care for vulnerable
populations will suffer significant financial losses. As a result,
these agencies will be forced to lay off staff or close their doors
altogether, resulting in significant job losses and further straining
state economies.
JFNA Recommends the Following Measures to Improve Care and Realize Cost
Savings in Medicaid
Although the Jewish Federations of North America must oppose the
Graham-
Cassidy amendment, we continue to stand ready to work with you, in
tandem with our Jewish communal health and long-term care providers, to
develop a new framework of policies to improve Medicaid quality,
efficiency, and sustainability. To this end, we offer the following
recommendations:
Rebalancing: The concept of rebalancing refers to shifting
Medicaid spending and resources from primarily financing long-term
services and supports in institutional settings to community-based
environments. Although skilled nursing facilities will remain vital
providers, rebalancing Medicaid reimbursement for community-based long-
term services and supports is both cost-effective and enhances quality
of life for many Medicaid enrollees. The Balancing Incentive Program
and the Money Follows the Person program are both designed to help
states shift Medicaid spending on long-term services and supports from
institutional settings to the community. Through these programs, states
have successfully expanded these services and transferred individuals
from institutional settings to their communities. Expanding rebalancing
within the Medicaid program so that Medicaid funding can be made
available for community-based long-term services and supports without a
waiver is both cost-effective and assures enhanced quality of life.
Promoting Telemedicine: Although expanding the use of
telemedicine and health information technology through long-term care
and behavioral health delivery systems will require an initial
investment in technology, it offers the promise of greater efficiency,
better and coordinated care, and significant cost savings.
Improving the Coordination between Medicare and Medicaid:
Medicaid and Medicare together provide health coverage for
approximately 10 million low-income seniors and people with
disabilities who are dually eligible for both programs. However,
Medicaid and Medicare generally operate as separate programs.
Beneficiaries have to navigate multiple sets of requirements, benefits,
and plans. Different coverage and payment policies can create
incentives to shift costs back and forth between the states and the
federal government, leading to underutilization of services in some
cases and overutilization in others. This lack of coordination between
the programs may also result in fragmented care, which can lead to high
costs and poor outcomes. The Dual-Eligible Special Needs Plans and the
Financial Alignment Demonstration Imitative are two programs working to
coordinate the financing structures and rationalize the administration
between the two programs to improve care and reduce costs. These two
programs should be explored further for their ability to improve care
while also reducing costs.
Increasing Value-Based Purchasing Initiatives: Value-based
purchasing models, such as Accountable Care Organizations increasingly
are being adopted in both Medicare and Medicaid. These models move away
from the traditional fee-for-service system and towards payment based
on quality and cost savings. Implementing these models more widely for
high-cost, high-need populations in need of long-term services and
supports could be a method to reduce costs while improving care for
beneficiaries and should be analyzed further.
Reducing Hospitalizations for Nursing Facility Residents: In
2011, the CMS Medicare-Medicaid Coordination Office implemented an
initiative to reduce avoidable hospitalizations of dually eligible
beneficiaries living in nursing facilities. Long-term care facilities
participating in the initiative have reported declines in all-cause
hospitalizations and potentially avoidable hospitalizations, as well as
reductions in Medicare expenditures. The second phase of this
initiative is underway and will test whether a new payment model for
long-term care facilities can improve quality of care by reducing
avoidable hospitalizations lower combined Medicare and Medicaid
spending. As the new results become available, if successful, this new
payment model could be expanded.
Promoting Prevention: Implementing preventive measures, such as
chronic disease management, health education, and other services
targeting high-risk groups, also may be able to lower Medicaid costs in
the long term. Wellness programs, such as diabetic education, prenatal
care, depression screening, and nutritional counseling, will improve
the health of patients and save scarce funds.
Expanding the Hospice Benefit: Expanding hospice education and
care in Medicaid, a strategy which has already realized cost savings in
Medicare, can reduce unnecessary treatment costs while enhancing the
quality of life for patients and their families.
In conclusion, JFNA opposes the Graham-Cassidy proposal because we
believe that it will have devastating consequences for vulnerable
populations and the providers who care for them. However, we stand
ready to work with you, in tandem with our Jewish communal health and
long-term care providers, to develop a new framework of policies to
improve Medicaid quality, efficiency, and sustainability.
Sincerely,
William C. Daroff,
Senior Vice President for Public Policy and Director of the Washington
Office
______
LeadingAge
2519 Connecticut Avenue, NW
Washington, DC 20008-1520
P 202-783-2242
F 202-783-2255
http://leadingage.org/
LeadingAge appreciates this opportunity to comment on the impact of the
Graham-Cassidy-Heller-Johnson Proposal on older Americans and the
nonprofit organizations that provide essential long-term services and
supports to them. We appreciate the Committee's efforts to ensure that
all Americans have access to quality, affordable health care.
The mission of LeadingAge is to be the trusted voice of aging. Our
6,000+ members and partners include nonprofit organizations
representing the entire field of aging services, 38 state associations,
hundreds of businesses, consumer groups, foundations and research
centers. LeadingAge is also a part of the Global Ageing Network, whose
membership spans 30 countries. LeadingAge is a tax-exempt charitable
organization focused on education, advocacy and applied research.
Our comments focus on the devastating impact that eliminating the
federal commitment to Medicaid will have on older persons and on
persons with disabilities.
CHANGING THE FINANCING STRUCTURE TO PER CAPITA CAPS
WOULD DEVASTATE THE PROGRAM
We oppose efforts to convert Medicaid to a per capita or block grant
allocation to the states because this would threaten the security of
millions of people who count on the program in their later years. They
would no longer have the certainty that the long-term services and
supports they need would be covered because Medicaid funding would no
longer be assured.
Medicaid has become the default payer for long-term services and
supports because there are no significant alternative sources of
payment other than out-of-pocket. As of 2013, over one-third of all
Medicaid expenditures went towards paying for long-term services and
supports. People in need of long-term care are often the oldest and
frailest Americans, many with complex health conditions. They have few
options and very few can pay for these services on their own. Medicaid
is essential to enabling them to live out their later years with
dignity and support.
Per capita caps and block grants would radically restructure Medicaid's
financing so much that the program would be simply unrecognizable from
its current form. When the specified federal match is no longer
guaranteed, the per capita caps could be subject to change during every
budget crisis or need for a pay-for. Funding could be reduced, the
inflationary adjustor decreased, and so forth.
Per capita caps and block grants would also cut Medicaid deepest
precisely when the need is greatest because funding would no longer
increase automatically during public health emergencies or in response
to the emergence of new treatments. The aging of the baby boomers would
make the federal Medicaid cuts worse over the long run because per
capita caps would make no distinction between the ``young-old,'' and
the ``old-old'' (85 and older). This is in stark contrast to the
federal/state partnership that exists today.
States already have substantial flexibility and can request waivers to
make Medicaid meet their unique needs. The Administration has already
committed to making state flexibility in Medicaid a cornerstone of its
plans. There is no need to cap the federal contribution to the program
to do this.
To compensate for substantial cuts to Medicaid, states would have to
raise taxes, make drastic cuts in other budget areas, restrict
eligibility, or otherwise cut Medicaid spending--seriously harming
beneficiaries. The draconian cuts under per capita caps or block grants
would shift more costs to states, causing millions to be uninsured or
reducing access to care.
In June of this year, LeadingAge and the Center for Consumer Engagement
in Health Innovation published the report ``Capping Medicaid: How Per
Capita Caps Would Affect Long-Term Services and Supports and Home Care
Jobs'' which analyzed the impact of per capita caps (PCC) on states'
ability to fund Medicaid long-term services and supports (LTSS). In
summary, we found five significant challenges that states would
confront, all of which are likely to influence the ability of each
state to adapt to payment by per capita cap (Table 1, p. 4):
1. The rate of growth of the over 85 population between 2015 and
2025 is not addressed by an inflation rate that is based on population
growth. A rapidly growing ``older'' old population has significantly
greater needs and will require more LTSS resources than the PCC rate
will finance. The gap between cap and costs of addressing growing need
will fall to the state.
2. The cap does not account for the increase in the expected
growth of the population over 65 with four or more chronic conditions;
again the states will be left to figure out how to pay for LTSS for
this population.
3. States that currently rely on above-average federal Medicaid
support will be hardest hit and least able to make up the difference,
thus forcing cuts in services or increases in state spending.
4. The increase in an old-old population with significant chronic
conditions that cannot be cared for at home will put significant
pressure on states that have expanded their home and community based
services to re-allocate funds to nursing homes. This will have a
negative impact both on the individuals who deserve to be served at
home, and the paid home-based workforce.
5. States with higher spending will be forced to cut back, thus
impacting the level of services available and placing greater stress on
families that already contribute significant support to their loved
ones.
Imposing per capita caps on Medicaid will not make the system more
rational or more effective, and we urge the Committee to oppose
shifting the Medicaid program to a per capita cap financing system.
THE NEED FOR AN EFFECTIVE SYSTEM FOR PAYING FOR
LONG-TERM SERVICES AND SUPPORTS
In 2015, over 6 million people had a serious condition that caused them
to need help with their health and personal care; the Department of
Health and Human Services estimates that that number will grow over the
next 50 years to 16 million. Medicare does not cover LTSS, yet about
70% of people over age 65 will require some type of LTSS at some point
during their lifetime. As our population ages, the need for these
services will only grow. In addition, about 40% of the individuals who
need LTSS are under age 65, and obtaining assistance with services in
their home can enable these individuals to work and be productive
citizens.
Regardless of when individuals need these services, there is a lack of
financing options to help them plan and pay for the services they need
to help them live independently in their homes and communities where
they want to be. Family caregivers are on the frontlines. They provided
care valued at $470 billion in 2013--more than the total spending on
Medicaid that year.
Only 11% of older adults had private long-term care insurance in 2014.
While private insurance can help people pay for the cost of services,
it is not affordable for most, and many people do not qualify for it.
Too often, the cost of services wipes out personal and retirement
savings and assets that are often already insufficient. As a result,
formerly middle class individuals are forced to rely on Medicaid to pay
for the costs of LTSS. There are few options for individuals to help
them pay for the services they need that could help them delay or
prevent their need to rely on Medicaid, the largest payer of LTSS.
For close to 30 years policy makers, advocates and consumers have
struggled to identify the most effective ways to finance long-term
services and supports. LeadingAge strongly believes that a coherent
financing mechanism for LTSS is essential to protecting families from
economic peril and providing adequate funding for the LTSS system to
support high-quality, community-based services that promote dignity and
independence, as we noted in our 2017 report, ``A New Vision for Long-
Term Services and Supports.'' We believe that we need to be having this
debate--how to pay for LTSS--not how to cut the Medicaid program.
In addition, the role of affordable housing in improving health care
and reducing costs cannot be discounted. The evidence is undeniable
that housing plus services models lead to smarter spending, increased
access to care, and better outcomes. Our members are at the forefront
of providing housing with coordinated services and can attest to the
enormous value that this combination provides to low income seniors and
people with disabilities.
CONCLUSION
LeadingAge urges the Committee to reject the Graham-Cassidy-Heller-
Johnson proposal. We urge Congress to begin a serious conversation
between lawmakers, consumers, and providers on LTSS.
Medicaid continues to be the fundamental source of payment for LTSS,
just as Medicare is the fundamental source of payment for post-acute
care services. Protecting the Medicaid program from the devastating
impact of reduced funding and elimination of the federal commitment by
imposing a per capita cap financing structure is critical to the
foundation for a more effective system.
We are more than willing to work with the Committee and Congress to
address these critical, challenging needs.
______
Little Lobbyists
P.O. Box 2052
Silver Spring, MD 20915
https://www.littlelobbyists.com/
September 25, 2017
U.S. Senate
Committee on Finance
Dirksen Senate Office Building
Washington, DC 20510-6200
RE: Hearing to consider the Graham-Cassidy-Heller-Johnson proposal
Chairman Hatch, Ranking Member Wyden, and Members of the Senate Finance
Committee:
We are Little Lobbyists, an organization comprised of families from
different states and from across the political spectrum, with one thing
in common: we have children with complex medical needs who require
significant medical care. Our mission is to advocate on behalf of the
hundreds of thousands of such children across the country, the most
vulnerable among us, to ensure that their stories are heard as part of
the ongoing health care debate and that their access to quality,
affordable health care is protected.
We visited each of your offices over the summer--some multiple times--
and hand-delivered stories of medically complex children living in your
state. We did this to make sure that their voices were heard; to give
you an appreciation for the issues these children and their families
face and an understanding of how crucial certain protections under
current law are to their livelihoods. Our hope was that you would think
of these children when considering new legislation, and make efforts to
protect their access to the quality, affordable health care they need
to survive.
We write now to speak out emphatically against the latest proposed
legislation, the Graham Cassidy-Cassidy-Heller-Johnson bill (Graham-
Cassidy), which in its hasty construction will jeopardize the health
and future of medically complex children in this country and rob their
families of the measure of security they have under current law. Our
children require far better--both in policy and procedure--than this
bill shows them.
There is no debate that our nation's health care system can, and must,
be improved. There is also no debate that taking funding and legal
protections away from medically complex children does not improve our
health care system. Unfortunately, that is what this bill does. The
Graham-Cassidy bill undermines three protections in current law that
are vital to the health and well-being of medically complex children
and their families.
1. Significantly decreased Medicaid funding
Even for families, with medically complex children, fortunate enough to
have good, private health insurance, this insurance frequently does not
cover home/community-based care (such as private duty nursing) and
therapeutic care that many medically complex children require. Medicaid
often fills this gap, and allows these children the ability to live at
home, attend school, and get the care they need to achieve their
potential and live as independently as possible.
Graham-Cassidy's radical upheaval of Medicaid will cut hundreds of
billions of dollars nationally from the program relative to current
law, with no guarantee that the funds must be spent on the same
populations. Under such dramatic funding reductions, it is virtually
impossible that the Medicaid services our children depend on will not
be negatively affected.
At even greater risk, and of utmost importance to our families, are
optional Medicaid programs like the Katie Beckett Medicaid waiver
program created by Ronald Reagan. This program allows families that
normally would not qualify for Medicaid to do so on account of the
significant medical care expenses their children incur. This allows
these families to care for their children in the home/community
setting, rather than forcing them into institutions. The funding
reductions in Graham-
Cassidy will force states to prioritize mandatory programs, placing
optional Medicaid programs such as Katie Beckett waivers first in line
on the chopping block. In short, under Graham-Cassidy, the vital safety
net that Medicaid provides many of our families will be pulled away,
leaving us to worry constantly whether it will be there when we need
it.
2. Elimination of the Affordable Care Act's prohibition on annual/
lifetime limits
Many of our children accumulated millions of dollars in medical bills
before they took their first breath outside of a hospital. Thankfully,
under the Affordable Care Act (ACA). Insurance companies are prohibited
from taking insurance coverage away from our kids if their care reaches
a certain dollar amount. The emotional stress that comes with having a
sick child in a hospital for weeks, months, or years is beyond
description. Imagine adding to that the stress of constantly worrying
whether it will be the next procedure, the next surgery, the next
medication, that will take away your child's health insurance forever,
and the guilt associated with rationing medical care for your child to
avoid that possibility.
Graham-Cassidy will make this a reality. Parents of medically complex
children will no longer have the security in knowing, for certain, that
their insurance company will not impose a cap on their child's health
care. Graham-Cassidy would allow states the ability to waive ACA
protections, including the ban on lifetime/annual caps on care. Whether
or not the state ever does so, it will always be an ever-present source
of anxiety for families with children who are medically complex. If
this protection were eliminated, which many states stand ready to do,
the financial impact on these families and the health impact on their
children will be devastating.
3. Elimination of the ACA's prohibition on pre-existing condition
discrimination
Medically complex children, by definition, have multiple pre-existing
conditions, often since birth. Under the ACA, our families have
certainty that our children will not face unaffordable increased
premiums, or be unable to find health insurance altogether, because of
conditions they have, through no fault of their own. We are able to
focus on getting the right care for our children, not constantly
engaging in a war with insurers over how much they will penalize us for
our children's conditions.
As with the issue of lifetime limits, Graham-Cassidy takes away from
our families a bright-line protection we desperately rely on, and
replaces it with a provision allowing states to waive it. We are given
vague assurances that our children will be protected and that our
insurance will continue to be ``affordable''--language in the bill
that, without definition, is meaningless and subject to any
interpretation. Indeed, the virtually unanimous opinion among non-
partisan health policy organizations is that the bill can, and will, be
used by numerous states to dramatically roll back the pre-existing
condition protections under current law. It is an unimaginable and
unacceptable risk to our families.
We hear Republicans in Washington tell us that Graham-Cassidy will give
consumers more ``flexibility'' and ``choice.'' How is that remotely
true, or helpful, for our families and our children? This bill would
fundamentally disrupt the protections our families depend on. The
``flexibility'' the bill offers comes at the cost of our security. And
the only ``choice'' it would likely provide us is an unthinkable one:
incur debt far beyond our means, or forego medical care that will keep
our children alive and able to achieve their potential.
As we said at the outset, we recognize that our nation's health care
laws can, and must, be fixed. But it is unjust, immoral, and contrary
to any meaning of ``pro-life'' to pass a law that will make it harder
for medically complex children to access the care they need, merely to
score a political victory within an arbitrary, self-imposed deadline.
Our children have done nothing wrong. They do not lack personal
responsibility; in fact, they show more strength, courage, and
resiliency in a single hospital visit than many people do in their
entire lives. They are just kids who, through no fault of their own,
need a little help.
You can help them now. Stand with our children. Hear their stories.
Ensure their access to health care is not diminished. We urge you to
turn away from this hastily considered and damaging bill, return to
regular order with committees and multiple hearings, and do the
difficult but necessary work of finding bipartisan solutions that will
improve health care access and affordability for Americans.
Sincerely, The Little Lobbyists
Co-Founders: Elena Hung, Silver Spring, MD (mother of Xiomara, age 3)
Michelle Morrison, Laurel, MD (mother of Timmy, age 6)
Steering Committee: Austin Carrigg, Tucson, AZ (mother of Melanie, age
5), Anna Kruk Corbin, Hanover, PA (mother of Jackson, age 12, and
Henry, age 9), Laura Hatcher, Towson, MD (mother of Simon, age 11), and
Benjamin Zeitler, Hyattsville, MD (father of Pierce, age 3)
Co-signed by the following families of medically complex children across
the country:
Michael Corbin, Joe and Takako Newman, Tyler and Maggie
Hanover, PA (father of Campbell, CA (parents Wells, Ringgold, GA
Jackson, age 12, and of Natalie, age 4) (parents of Rowan,
Henry, age 9) age 14 months)
Brian Hatcher, Towson Kristin and Nick Jennifer Harris,
MD (father of Simon, Chaset, San Francisco, Lawrenceville, GA
age 11) CA (parents of Megan, (parent of Hannah,
age 2) age 10)
Sanghee and Eric Lynn, Elizabeth and Eric Tera Fulmer. Augusta,
Washington, DC Katsuleres, Vallejo, GA (parent of Eva,
(parents of Teddy, age CA (parents of Joseph, age 2)
6) age 2)
Mark Morrison, Laurel, Sarah Victoria Jaque- Ann and Mike Weaver,
MD (dad of Timmy, 6) Kamp, Ph.D., Gregory Naperville, IL
Kamp, Santa Clarita, (parents of Tim, age
CA (parents of 23)
Cameron, age 18)
Caroline Brouwer, Justin and Jenny Mary Cotton,
Rockville MD (mother McLelland, Clovis, CA Coulterville, IL
of Elliott, age 1) (parents of James, age (parent of Wyatt, age
6) 5)
Erin Mosley, Silver Merce Wynne, Valencia, Zachary Bartelt and
Spring, MD (parent of CA (parent of Wolfie, Charlotte Bolthouse
Addison, age 6) age 5) Bartelt, Rockford, IL
(parents of
Angelique, age 4)
Jill Messier, Highland, Angela Howard, Marissa Arevalo,
MD (parent of Centennial, CO (mother Peoria, IL (parent of
Christopher, age 22) of Laura, 3) Rocio age 5)
Samantha McGovern, Amanda Scott and Akeem Stephanie Wyatt,
Springfield VA (parent Green, Lakewood, CO Danville, IL (mother
of Josephine age 1) (parents of Dakarai, of Christopher, age
age 3) 13)
Todd and Angie Voyles, Lorena and Michael Julie Corbier de Lara,
Haymarket, VA (parents DeCarlo, Fairfield CT Evanston IL (mother
of Annalyse, age 5) (parents of Lucas, age of Michael age 13)
1)
Rebecca Wood, Michelle and Oliver Leona Blitzsten,
Charlottesville, VA Marti, New Canaan, CT Chicago, IL
(parent of Charlie, (parents to twins Max (grandparent of
age 4) and Nick, age 8) Michael)
Kim Crawley, Ashburn, Veronica Hernandez, Barry Blitzsten,
VA (mom of Isaac age Cheshire, CT (mother Chicago IL (uncle of
8) of Arianna, age 3) Michael)
Jamie Foster, Pleasant Tracy Tardiff, New Margaret Storey and
Plains, AK (parent of Hartford, CT (parent Jonathan Heller,
Rowan, age 8 months) of Sophia, age 9) Evanston, IL (parents
of Josie, age 14)
Heather Swanson, Michelle and Oliver Susan Agrawal,
Anchorage, AK (parent Marti, New Canaan, CT Chicago, IL (parent
of Connor, age 11) (parents to twins Max of Karuna, 2003-2014)
and Nick, age 8)
Michelle Gray, Madison, Charlie and Kristen Guiller Bosqued and
AL (parent of Emmet, Patterson, Shea Ako, Chicago, IL
age 3) Tallahassee, FL (parents of
(parents of Hadley, Alejandro, age 6)
age 5)
Nancy Smith, Hoover, AL Carolyn Murray, Jeff and Pamela
(parent of Ivan, age Jacksonville, FL Marshall, Peoria, IL
7) (mother of Daniel, age (parents of Ethan,
18) age 7)
Susan Colburn. Todd and Cindy Vickers, Jody Prunty, Wheaton,
Montgomery, AL Warner Robins, GA IL (mother of Sophie,
(parents of Philip and age 23)
Emily, twins age 3)
Charlotte Hurley, Janna Blum, Ph.D. and Nicole and Robert
Phoenix, AZ (parent of Richard Blum, Ph.D., Boudreau, Aurora, IL
Matthew, age 2) Atlanta, GA (parents (parents of Ella, age
of Abigail and Elijah, 2)
twins age 3)
Jennifer Foster- Abby Brogan, Wayland, Nicole Gerndt,
Degillo, Chandler, AZ MA, (mother of Ellie, Brookfield, IL
(mother to Evander, age 11) (mother of Finley,
age 6) age 7)
Marsheila Rockwell, Gretchen Kirby, Kellie and Derek
Gilbert, AZ (parent of Amesbury, MA (mom to Colby, IL (parents of
Max, age 8) Adrien and Tavish, age Chase, age 1.5)
11, and Keva, age 10)
Gabriela and Eugene Gwendolyn Harter and Eric and Natalie Hart,
Mafi, Los Alamitos, CA Adam Hall, Ashton, MD Burlington, NC
(parents of Gabriel (parents of Jackson, (parents of Collier,
Mafi, 22 months) age 12) age 3)
Jamie Austin, St. Kathleen and Roger Dania Ermentrout and
Charles, IL (parent of Dartez, Baltimore, MD Daniel Smith,
Kiara, age 4) (parents of Roman, age Greensboro, NC
12) (parents of Moira,
age 5)
Roberta Holzmueller, Amy Copeland, Bethesda, Samantha Stallings, NC
Evanston, IL (parent MD (parent of David, (parent of Johnathan)
to Aaron, age 17) age 4)
Francois Corbier de Marie and David Kate Eardly,
Lara, Evanston, IL Anderson, Baltimore, Charlotte, NC (parent
(father of Michael) MD (parents of Ramona, of Sloane, age 3)
age 5 months)
John Hart, Cedar Lake, Katie Angerer, Justin and Jamie
IN (father of Harley, Reisterstown, MD Burton, Staley, NC
15 months) (parent of Lucy, age (parents of Eli, age
4) 8)
Dr. Jason and Heather Kristin and Michael Mitzi Cartrette,
Tanner, Fort Wayne, IN Stelmaszek, Novi, MI Pfafftown, NC
(parent of Colton, age (parents of Emmaline, (guardian of Ashton,
4) age 7) age 11)
Alicia Halbert, Penny Millirans, Battle Crystal Bryant,
Indianapolis, IN Creek, MI (parent of Lexington, NC (parent
(mother of Rory, 12) Joseph, age 9) of Caitlin, age 2)
Ashley and Adam Hill, Mary Ann and Dennis Natalie Weaver,
Fort Wayne, IN Fithian, Dexter, MI Cornelius, NC (parent
(parents of August, (parents of Faith, age of Sophia age 8)
age 4 months) 11)
Becky Hufty, Tricia Mihalic, Jeff and Jill Bass,
McCordsville, IN Traverse City, MI Rocky Mount, NC
(parent of Jack, age (parent of Nick, age (parents of Carli,
10) 17) age 11)
Emily Altemus, Bill and Elaine Nell, Stuart and Rebecca
Valparaiso, IN (mother Clemmons, NC (parents Galbreath, Charlotte,
of Sebastian, age 5) of Lydia and Carol NC (parents of Jake,
Nell, twins age 5) age 3)
Jane and Fred Fergus, Sarah Potter, Toby Lunstad, Mandan,
Lawrence, KS (parents Pfafftown, NC (parent ND (parent of
of Franklin, age 8) of Matt, age 30) Addilynn, age 2)
Angeliina and Jonathan Cassandra Littlefield, Philip and Alison
Lawson, Shawnee, KS Durham, NC (parent of Chandra, NJ (parents
(parents to David, age Clark, age 3, and of Ethan, age 3)
7) Joshua, age 7)
Theresa Lemire, Tamarin and Jonathan Hilary and Jeremy
Shawnee, KS (mother of Zoppa, Mooresville, NC Biehl, Santa Fe, NM
Melissa, age 24) (parents of Gabriella, (parents of Aidan,
age 7) age 3)
Carol Smith, Stacy Staggs, Sandra Stein, New
Williamsburg, KY Charlotte, NC (mother York, NY (mother of
(parent of Gunner, age of Emma and Sara, Ravi, age 8)
3) twins age 4)
Mike and Crystal Bethany and Jared Josh Fyman, West
Simpson, Bell Count, Reeves, Garner, NC Hempstead, NY
KY (parents of Gunnar, (parents of Naomi, age (parents of Penny,
age 22 months) 18 months) age 6)
Kelly and Emily Marybeth Weber, Susan Demrick
Greenwell, Union, KY Slippery Rock, PA Koprucki,
(parents of Quinn, age (mother of Janessa, Williamsville, NY
3) age 7)
Kodi Wilson, Baton Jennifer Rath, Mars, PA Dianna and Chris Ryan,
Rouge, LA (parents of (parent of Austin, age Pleasantville, NY
Braden, age 11) 11) (parents of Emma, age
4)
Ashley Myers, Metairie, Nicole White, Cranston, Michele Juda, Ballston
LA (mom of Fiona, age RI (mother of Kyrie, Spa, NY (parent of
8) age 5) Devon, age 16)
Christine Heath, Trina Morgan, Debbie Buxton, New
Monson, MA (mother of Greenville, SC (parent York, NY (parent of
Joshua, age 16) of Marge, age 16) Joey, age 15)
Caitlin Crugnale, Lisa Annette Stanley, Lisa Lucas,
Holbrook, MA (parent Houston, TX Georgetown, TX
of Benjamin, age 5 (grandmother of (parent of Hannah who
months) Solomon, age 2) now resides in
Heaven, but I stand
with these families
with medically
fragile children)
Cindy Hammerquist, Brenda Martinez, San Julie Melton,
Huntington, NY (mother Antonio, TX (parent of Levelland, TX (parent
of Thomas, 10) Miranda, age 10) of Michael, age 4)
Craig and Julie Yoder, Hannah and Manish Nicole Ritchey,
Sugarcreek, OH Mehta, Flower Mound, Oakhurst, TX (parent
(parents of Isabella, TX (parent of Aiden, of Kyler, age 22
age 8) age 10) months)
Heather Denchik, R.N., Josh Hebert and Kyla Ryan and Elizabeth
and Andrew Denchik, McKay, Pasadena, TX Baker, Katy, TX
MBA, Centerville, OH (parents of Katie, age (parents of Grayson,
(parents of Reid, age 12) age 7)
4)
Nicole Stargel, Gillian Quinn, Houston, Jennifer and Matt
Kettering, OH (mother TX (parent of Raphael, Jennings, Grand
of McCarthy, age 17) age 1) Prairie, TX (parents
of Mya, age 5)
Carol Combs, Hamilton, Jill and Jason Korrie Everett,
OH (mother to Grayson, Bradshaw, Austin, TX McKinney, TX (parent
age 9) (parents of Elise, age of Henry, age 14, and
4) Robin and Abigail,
age 17)
Elizabeth Diamond, Nathan and Dominique Cynthia Ann Lopez, San
Danville, OH (mother Holzman, Cypress, TX Antonio, TX (parent
of Deacon, age 10) (parents of Aiden, age of Victor Angel
9) Ballez, III, age 12)
April Apsey, Fremont, Amber and Ronald Marin, Sharon Elizabeth
OH (parent of Alec, Houston, TX (parent of Robinson, Katy, TX
age 8) Jessica, age 4) (grandmother of
Grayson, age 7)
Stephanie Ziemann, Nishanth Menon and Marcelo and Jennifer
Toledo, OH (parent of Khairunnisa Hassanali, Garcia, El Paso, TX
Ada-Lily, age 7) Plano, TX (parents of (parents of Sadie,
Alisha, age 3) age 5)
Brian and Amy Vavra, Russell and Rebecca Mary Ocampo, Flower
Lakewood, OH (parents Germany, Kerrville, TX Mound, TX (parent of
of Evelyn, age 2) (grandparent and Angelica Ocampo, age
guardian of Aubrey, 15 months)
age 5)
Dr. Amy Rule, Carol and Bill Daley, Karen Merritt Kline,
Cincinnati, OH Arlington, TX (parents Houston, TX
(pediatrician and of Will Daley, age 13) (grandmother of
parent of Oliver, age Grayson, age 7)
1)
Jade and Jarod Day, Vicki Gilani, Houston, Maud Marin, Houston,
Muskogee, OK (parents TX (speech therapist TX (mother of Lucas,
of Gavin, age 9) for children 0-18) age 4)
Sierra Martin, Perry, Caroline Cheevers, Melissa Marrero, El
OK (parent of Weston Houston, TX (mother of Paso, TX (parent of
Ferrell, 6) Tyler, age 9, Justin, Jaxon, age 4)
age 7, Hailey, age 7,
and baby girl, age 3)
Autumn and Hayden Ryan, Shelia and Bill Heard, Jacqueline Gonzalez,
Tulsa, OK (parents of Beckville, TX (parents Houston, TX (mother
Charlie, age 8) of Adam, age 20) of Abel Gonzalez, age
16)
Sharon Link, Paul and Amelia Beatty, Eric and Jennifer
Downingtown, PA Annandale, VA (parents Schulze, Seguin, TX
(parent of Rachel, age of Orion, age 2) (parents of Garrett,
22) age 10)
Meghann Luczkowski, Debra Krieger, San Josh Fultz, Navasota,
Philadelphia, PA Antonio, TX (parent of TX (parent of Jadyn,
(parent of Miles, age Jeffrey, age 11) age 10)
3)
Sarah Palya, Butler, PA Corinne Kunkel, Lorton, Laura Leeman,
(parent of August VA (parent of Dylan, Colleyville, TX
Palya, age 13) age 5) (mother of Victor,
age 12)
Lisa Kinsey, Kennett Nicole Ritchey, Julie Ross, Dallas, TX
Square, PA (parent of Oakhurst, TX (mother (mother to Niko
Sarah, age 4) of Kyler, 22 months) Tigerlily, age 5)
Jennifer Zurn, Carolyn and Tim Scott and Shonda
Pittsburgh, PA (parent Anderson, Leesburg, VA Kincaid, Kilgore, TX
of Isaac, age 2) (parents of Maren, age (parents of Koen, age
2) 4)
Scott and Dena Dupuie, Eric and Katrina Young, Maud Marin, Houston,
Driftwood, TX (mother Norfolk, VA (parents TX (mother of Lucas,
of Brianna, 10 years of Ethan, age 1) 4 yrs old)
old)
Jill Hutchings, Martha Kilburn, Brent and Suzette
Mckinney, TX (parent Roanoke, VA (mother to Fields, Cedar Park,
of Asher, age 6) Mya, age 16, and Dee, TX (parents of Chloe,
age 9) age 8)
Joshua and Kaya Courtney Anguizola, Alison and Bruce
Jackson, Austin, TX Seattle, WA Beckwith, Keller, TX,
(parents of Bree, age (parents to Alex, age
2) 13, and Maddy, age 3)
Elizabeth Smith, Matt and Katie Tammy Hodson,
Austin, TX (mother of Sullenbrand, Madison, Highland, Utah
Holden, 4 months) WI (parents of Eve, (parent to Parker age
age 6) 12, currently
inpatient at Primary
Children's Hospital)
Steven and Jeorgi Mary Maier-Hellenbrand, Amy Hill, Richmond, VA
Bernard, Salt Lake Waunakee, WI (parent of Declan, 1
City, UT (parents of (grandmother to Eve, year old)
Iris, age 21 months) age 6)
Babita Desai, Leesburg, Kristen Peterson, Lac Craig and Lindsay
VA (parent of Ryan du Flambeau, WI Lykens, Ashburn, VA
Desai, age 5) (mother of Sage, 8 (parents of Gillam,
months) age 23 months)
Marta and Mike Conner, Brian and Christina Megan and Tony Parisi,
Clifton, VA (parents Spencer, Alexandria, Madison, WI (parents
of Caroline, age 7) VA (parents of of Vincent, age 10)
Memphis, 5 months)
Christy Judd, Inwood,
WV (mother of Ethan,
age 8)
______
Letter Submitted by Don and Laurine Lusk
September 22, 2017
Regarding: Stop the Graham-Cassidy-Heller-Johnson proposal, which would
harm people with disabilities and seniors.
We have a daughter, Megan, who is 37 years old. She was born with
autism and intellectual/cognitive disabilities. Later she also
developed spinal deformities of Kyphosis (curve of her upper spine) and
Scoliosis (side to side curve of her entire spine). And she developed
severe vertigo.
In the Nation's dark history, not too many years ago, Megan would have
been sent to an institution when she was born, so she could spend her
lifetime shut away from the community. But in the 1960s the ``community
integration'' movement took hold and Wisconsin and the entire Nation
began providing needed services to people in their homes and other
community settings. In 1980, the special education mandate was passed,
to ensure children with disabilities access to public education. And in
1990 the Birth to 3 mandate helped to ensure that infants and toddlers
with disabilities would be helped by early intervention services, so
learning could be maximized at a time when the brain was undergoing
tremendous growth and change.
You may wonder why these community-based services were mandated, so I
will share what we have learned. For every $1 spent in community-based
services, including services to babies, children, teens, and adults . .
. there is a 1,000% return in the person becoming more capable and
independent. The lives of people with disabilities and other community
members are enriched. People with disabilities work jobs, volunteer,
pay taxes, and vote. The alternative to community based support is
institutional care, and that segregated care cost much more per day
while warehousing people in settings where abuse was rampant.
So why would the House and/or Senate consider cuts to Medicaid dollars
that are necessary for people to live and work within their
communities, while producing huge savings when compared to
institutionalization? At first I thought it was mere ignorance or
prejudice on the parts of Senators Graham, Cassidy, Heller, Johnson and
the others who proposed Medicaid cuts in earlier attempts to pass
changes to the Affordable Health Care Act. But we've come to realize
that there may be a pervasive belief that people with disabilities and
seniors who rely upon Medicaid for life-saving services . . . aren't
worth keeping alive. Instead, it appears that many in Congress and the
President wish to repay powerful individuals and corporations who
funded their political campaigns. So, if Congress and the President can
cut life-saving funds from America's most vulnerable, causing them to
be institutionalize and/or to die, then their debt to wealthy and
powerful corporations and individuals can be repaid through huge tax
breaks for the rich. Do you think that we don't see this unfolding? It
is clear that many politicians are working only for themselves and
certainly are not working for their constituents! For that reason . . .
we say this is America's shame! And anyone who supports cuts to
vulnerable citizens, to give more to the rich . . . SHAME ON YOU!
Throughout her lifetime, Megan has received Medicaid funded therapies
and instruction. As an adult she now works two jobs, owns a condo, and
she pays income and real estate taxes. If Congress succeeds in cutting
or block granting Medicaid, Megan will no longer have the staff support
needed to continue her two jobs or to maintain her home. Her needs are
severe and years of evaluations have documented that she meets the
``nursing home level of care'' which means that we know cuts to
Medicaid will result in her institutionalization.
Ignorance is not an excuse for what Congress and the President are
attempting to do to Medicaid. And bruised male egos that can't handle
the fact that people call the Affordable Health Care Act ``Obamacare''
are also no excuse.
It doesn't matter the reason some in Congress wish to remove the safety
net from millions of seniors and people with disabilities, including:
To gather money for tax breaks for the rich, so these
politicians can expect payback through campaign funds to help them win
future elections, or
Republican party bruised egos over a Democratic President
championing a great health care law, or
White Supremacy anger over a black President serving the country
by passing the Act, or
Prejudice against people with disabilities, or
Ignorance about the fact that institutions are more expensive
and inhuman.
All of the above reasons for writing or supporting the terrible changes
outlined in the Graham, Cassidy, Heller, Johnson proposal, and the
previous similarly terrible proposals to cut or block grant Medicaid
must be stopped! If not, thousands will die and millions will be
institutionalized. This is unconscionable and certainly does not
constitute representation of your constituents. As other countries rush
to help people in their countries who are harmed by storms and
earthquakes, America is witnessing a rise in a new, greedy, self-
serving mentality that is obviously causing Congress to intentionally
harm and kill the country's most vulnerable citizens, seniors and those
with disabilities. They must be stopped! The Graham, Cassidy, Heller,
Johnson proposal must be stopped, as the earlier proposals were
stopped.
Congress must pull their focus away from their bruised egos and their
wish to please their rich co-conspirators and, instead, represent
constituents like our daughter Megan and the millions of others who
wouldn't be able to get out of bed, dress, eat, use the bathroom, or be
employed if Medicaid funds were reduced. Stop playing around with
Medicaid. Everyone who votes has an elderly person in their family, and
at least 1 in 12 have someone with a disability in their family. And
there are millions of doctors, nurses, vocational and residential
caregivers who are watching the cruel politics playing out in
Washington, DC. We are a huge voting block and we are disgusted by what
we are watching Congress do. It's time to improve those few issues in
Obamacare, while working between parties. Bring back advertisement for
the Affordable Care Act, reassure providers, and stabilize the
marketplace. Stop doing damage by intentionally sabotaging a good law.
Remember who you are to represent . . . we the people!
Don and Laurine Lusk
______
March of Dimes Foundation
Office of Government Affairs
1250 H Street, NW, Suite 400B
Washington, DC 20005
Telephone (202) 659-1800
Fax (202) 296-2964
https://www.marchofdimes.org/
On behalf of the March of Dimes, a unique collaboration of scientists,
clinicians, parents, members of the business community, and other
volunteers representing every state, the District of Columbia and
Puerto Rico, I appreciate this opportunity to submit testimony for the
record of the hearing to consider the Graham-Cassidy-Heller-Johnson
health care proposal.
I will be blunt: this legislation poses a dire threat to the health of
women, infants and families across our nation and should be rejected
outright by every Senator.
In particular, the Graham-Cassidy-Heller-Johnson bill poses a special
danger to pregnant women and infants, some of the most vulnerable
populations. At every turn, this proposal rejects approaches that would
make it easier for women and families to obtain affordable,
comprehensive care, instead erecting barriers to coverage and removing
critical consumer protections.
The March of Dimes is particularly concerned about the impact of this
proposal in three areas: Medicaid, the individual insurance market, and
state health care systems.
Medicaid Impacts Would Be Devastating
Each year, approximately half of all births in the U.S. are covered by
Medicaid.\1\ Millions of pregnant women receive comprehensive prenatal
care under Medicaid, and their infants are covered for hospitalization,
vital well child care, and illness. Medicaid also covers a
disproportionate share of high-risk births.\2\ In many states, Medicaid
provides crucial wraparound services for families who have private
coverage, but whose children face major health crises with catastrophic
costs. For millions of families, Medicaid can make the difference
between a healthy or sick pregnancy or baby, and serves as a bulwark
against financial ruin for families of medically complex children.
---------------------------------------------------------------------------
\1\ Markus, A.R., Andres, E., West, K.D., Garro, N., and
Pellegrini, C., ``Medicaid covered births, 2008 through 2010, in the
context of the implementation of health reform,'' Women's Health Issues
2013;23(5):e273-e280.
\2\ Markus, A., Garro, N., Krahe, S., Gerstein, M., and Pellegrini,
C., ``Examining the Association Between Medicaid Coverage and Preterm
Births Using 2010-2013 National Vital Statistics Birth Data,'' Journal
of Children and Poverty 2016;23(1):79-94.
Under the Graham-Cassidy-Heller-Johnson bill, states would lose the
ability to cover additional populations under Medicaid, as permitted
under the Affordable Care Act (ACA). The March of Dimes estimates that
this rollback alone would result in up to 6.5 million women of
childbearing age losing coverage,\3\ denying them the opportunity to
get healthy before they get pregnant. Many of these low-income women
would have no recourse for obtaining coverage or health care.
---------------------------------------------------------------------------
\3\ http://www.marchofdimes.org/news/statement-of-stacey-d-stewart-
president-march-of-dimes-on-release-of-the-better-care-reconciliation-
act.aspx.
The bill would also convert the existing Medicaid program from an
entitlement program to a combined block grant and per capita cap
funding structure, potentially wiping out the current requirements that
states cover certain mandatory populations, such as pregnant women and
children. In addition to these likely coverage losses, the conversion
of Medicaid from an entitlement to a capped system is expected to
eliminate numerous patient protections in the name of state
flexibility. For example, states might no longer be required to adhere
to the Early Periodic Screening, Diagnostic and Treatment (ESPDT)
---------------------------------------------------------------------------
standard of providing medically necessary care to children.
Finally, the Graham-Cassidy-Heller-Johnson bill is estimated to reduce
federal funding Medicaid by over $713 billion through 2026 alone.\4\ It
is simply impossible to drain this degree of resources from our health
care system without extensive consequences for patients, providers, and
other stakeholders. States will be forced to serve fewer people, offer
fewer services, cut payments to doctors and hospitals, raise taxes, or
some combination of all of these measures.
---------------------------------------------------------------------------
\4\ http://avalere.com/expertise/managed-care/insights/graham-
cassidy-heller-johnson-bill-would-reduce-medicaid-funds-to-states-by.
---------------------------------------------------------------------------
The Individual Market Would Revert to Only Serving the Healthy
Under the Graham-Cassidy-Heller-Johnson proposal, the Affordable Care
Act's provisions around Marketplaces would be eliminated and states
would receive funds to establish their own systems. In the name of
flexibility, states would be allowed to permit insurers to charge sick
people higher rates, not cover essential health benefits, and impose
caps on services and benefit levels.
In a nutshell, this bill would return us to the days when only healthy
people could afford coverage in the individual market. Allowing
insurance companies to engage in medical underwriting again will almost
certainly set off a ``race to the bottom,'' where insurers compete for
the healthiest customers by offering cheap plans that cover few
services. Lower premiums may be achieved, but they will only be
available to a limited population, and the plans with lower premiums
may not cover the services people actually need. Prior to passage of
the ACA, only 13% of plans in the individual market covered
pregnancy;\5\ in most cases, women who needed this coverage had to
purchase costly riders, or could not obtain maternity coverage at all.
Numerous analysts have noted that maternity and newborn coverage will
likely be among the first benefits insurers will choose to exclude from
plans.
---------------------------------------------------------------------------
\5\ https://www.marchofdimes.org/advocacy/affordable-care-is-
essential-to-moms-and-babies.as
px.
Among those states that waive the essential health benefits (EHB)
requirements, annual and lifetime caps will also make an unwelcome
reappearance. Because the ACA's prohibition on annual and lifetime caps
only applies to EHBs, the elimination of the EHB requirement will
functionally void the ban on caps. Once again, families will be find
themselves in dire straits when a single major illness or chronic
condition could render a child uninsurable permanently. In some cases,
an infant born extremely preterm or with other serious complications
could exhaust her lifetime limit before even leaving the hospital.
States Need Appropriate Time and Investment to Build New Health Systems
The Graham-Cassidy-Heller-Johnson bill envisions each state undertaking
the herculean task of building a new individual marketplace system in
only 2 years. While some states may be capable of producing a full-
fledged system within this timeframe, many will likely require more
time. If states must have functional systems by 2020, it is highly
probable that those systems will not adequately address the needs of
maternal and child health.
In fact, states are already struggling to serve maternal and child
health appropriately. For the past 2 years, preterm birth rates have
increased, after declining for the prior several years.\6\ Maternal
mortality rates across the U.S. exceed those in most developed
nations.\7\ In many U.S. communities, infant mortality rates rival
those of third world countries.\8\ Stark disparities exist among birth
outcomes for many racial and ethnic groups. Maternal and child health
serves as an exquisitely sensitive barometer for the effectiveness of
our health care system, and in too many communities it already
indicates serious problems.
---------------------------------------------------------------------------
\6\ https://www.cdc.gov/nchs/data/vsrr/report002.pdf.
\7\ http://www.who.int/reproductivehealth/publications/monitoring/
maternal-mortality-2013/en/.
\8\ https://www.cdc.gov/nchs/data/nvsr/nvsr63/nvsr63_05.pdf.
Moreover, the Graham-Cassidy-Heller-Johnson bill seems to expect that
states will be able to impose cost-containment efforts that the federal
government, with its more significant bargaining power and reach, has
not. Any serious attempt to restrain costs in our health care system
must recognize that the least effective approach is simply to reduce
spending. Instead, the government should closely examine the actual
drivers of costs and address them directly with targeted interventions.
One of the most effective ways to restrain costs would be to engage in
sensible, meaningful efforts to promote preventive care. For maternal
and child health, this would mean increasing access to well woman,
prenatal and well child care to improve outcomes for both mothers and
---------------------------------------------------------------------------
their babies.
States require time, resources, collaboration, and access to best
practices in order to construct a health care system that supports
healthy pregnancies, babies, and families. The Graham-Cassidy-Heller-
Johnson proposal provides none of the tools necessary to make that
possible.
Conclusion
Throughout our history, the March of Dimes has advocated for patient-
centered systems of care that expand access, improve quality, and
reduce costs for all parties in the system with the ultimate goal of
healthy pregnancies and healthy babies. Unfortunately, the Graham-
Cassidy-Heller-Johnson bill fails on all counts to satisfy these
standards. Expecting states to produce dramatically better outcomes
with radically fewer resources is little more than magical thinking.
The March of Dimes urges all Senators to oppose the Graham-Cassidy-
Heller-
Johnson legislation. This bill is bad medicine for pregnant women,
children, and families all across our nation.
______
The Michael J. Fox Foundation for Parkinson's Research
Grand Central Station
Post Office Box 4777
New York, NY 10163
www.michaeljfox.org
Statement of Ted Thompson, Senior Vice President, Public Policy
Chairman Hatch, Ranking Member Wyden, and Members of the Committee:
The Michael J. Fox Foundation for Parkinson's Research thanks the
Senate Committee on Finance for holding this hearing on the Graham-
Cassidy-Heller-Johnson healthcare proposal and appreciates the
opportunity to submit this written statement to share the perspective
of the between 750,000 and 1 million people in the United States living
with Parkinson's disease.
As the world's largest nonprofit funder of Parkinson's disease
research, The Michael J. Fox Foundation for Parkinson's Research is
dedicated to accelerating a cure for Parkinson's disease and developing
improved therapies for those living with the disease today. In
providing more than $750 million in research to date, the Foundation
has fundament ally altered the trajectory of progress toward a cure for
Parkinson's disease, which has an annual economic burden of between
$19.8 and $26.4 billion.
The Michael J. Fox Foundation for Parkinson's Research is incredibly
concerned that several of the provisions contained within the Graham-
Cassidy-Heller-Johnson healthcare proposal would have a distinctly
negative imp act on Parkinson's patients across the United States.
Maintaining the prohibition against pre-existing condition
discrimination and keeping the essential health benefits package intact
are imperative to preserving affordable access to quality healthcare
for Parkinson's patients. The Graham-Cassidy Heller-Johnson healthcare
proposal permits states, through waivers, to eliminate coverage for the
essential health benefits currently mandated by the Affordable Care
Act. This would allow states to erode coverage for individuals with
pre-existing conditions, such as Parkinson's disease, and subject them
to increased costs, as well as annual and lifetime caps.
Both chronic disease management and prescription drug coverage are part
of the essential health benefits package.\1\ The proposal provides
significant and nearly unrestricted flexibility to states by requiring
those seeking waivers to only explain the manner in which they intend
to maintain access to adequate and affordable coverage for individual's
with pre-existing conditions. There is, however, no requirement that
states demonstrate whether or not it is realistic or possible for such
access to be maintained. The net consequence of these waivers would be
that Parkinson's patients' protection against discrimination and access
to the essential health benefits will depend entirely upon the state in
which he or she lives, and the protections afforded by each state. This
is a dangerous and costly result for individuals with Parkinson's
disease who may be financially unable to access new and necessary
treatments.
---------------------------------------------------------------------------
\1\ ``Information on Essential Health Benefits (EHB) Benchmark
Plans,'' Centers for Medicare and Medicaid Services. Accessed on
September 21, 2017, https://www.cms.gov/cciio/resources/data-resources/
ehb.html.
Preserving the essential health benefits package is vital to
maintaining access to affordable, quality healthcare for Parkinson's
patients who obtain coverage through their employers. Large employer
plans are permitted to employ any state's definition of essential
health benefits when determining the breadth of the prohibition on
annual and lifetime limits to coverage.\2\ The waiver flexibility
permitted by the Graham-Cassidy-Heller-Johnson healthcare proposal
would allow large employers who provide coverage for Parkinson's
patients to elect to utilize essential health benefits packages
allotted by the least generous states, effectively subjecting employees
to annual and lifetime caps that may financially prevent them from
accessing the necessary care.
---------------------------------------------------------------------------
\2\ Matthew Fiedler, ``Allowing states to define essential health
benefits could weaken ACA protections against catastrophic costs for
people with employer coverage nationwide,'' The Brookings Institute,
May 2, 2017, https://www.brookings.edu/2017/05/02/allowing-states-to-
define-essential-health-benefits-could-weaken-aca-protections-against-
catastrophic-costs-for-people-with-employer-coverage-nationwide/.
Maintaining the prohibition against community rating is essential to
continuity of, and access to, quality healthcare for Parkinson's
patients. Currently, the Affordable Care Act prohibits the use of
actual or expected health status when setting group premiums.\3\
Community Rating protects individuals with pre-
existing conditions, such as Parkinson's disease, by ensuring that
premiums offered by insurance providers are the same for all
individuals within a specified geographic territory.
---------------------------------------------------------------------------
\3\ ``Adjusted Community Rating FAQs,'' United Healthcare, October
2013, https://www.
uhc.com/content/dam/uhcdotcom/en/HealthReform/PDF/Provisions/
AdjustedCommunity/ACR_FAQ.pdf.
The Graham-Cassidy-Heller-Johnson healthcare proposal would allow
states to waive this prohibition and permit insurers to charge higher
premiums to individuals based on health status. Without the safeguards
against community rating provided by the Affordable Care Act, premiums
based on health status for individuals with pre-existing conditions or
higher than average healthcare costs would skyrocket resulting in many
patients with Parkinson's disease being priced out of the market and
left without access to quality healthcare. Gaps in healthcare coverage
as a result of inaccessibility due to affordability is particularly
---------------------------------------------------------------------------
detrimental to Parkinson's patients.
Currently, up to one-third of the Parkinson's community are dually
eligible for both Medicare and Medicaid, leaving this population
particularly vulnerable to the impact of the allocation of scarce
resources by state Medicaid programs following federal funding cuts.
The Graham-Cassidy-Heller-Johnson healthcare proposal would repeal the
authority to cover adults through the Medicaid expansion immediately
for non-expansion states and by 2020 for expansion states, repeal the
enhanced Federal Medical Assistance Percentage for the Medicaid
expansion that currently covers 15 million adults, and make significant
cuts to traditional Medicaid.\4\, \5\ Furthermore, the
proposal would create capped block grants that combine federal funds
for the Medicaid expansion, cost-sharing subsidies, and Basic Health
Programs for low-income residents that would be lower than current
spending and would require states to limit coverage. These block grants
would maintain the aforementioned federal funding through 2026, with no
indication regarding funding after that date.
---------------------------------------------------------------------------
\4\ ``Compare Proposals to Replace The Affordable Care Act,'' The
Henry J. Kaiser Family Foundation, September 2017, http://
www.easybib.com/guides/citation-guides/chicago-turabian/how
-to-cite-a-website-chicago-turabian/.
\5\ ``Five Ways the Graham-Cassidy Proposal Puts Medicaid Coverage
at Risk,'' The Henry J. Kaiser Family Foundation, September 2017,
http://www.kff.org/medicaid/fact-sheet/5-ways-the-graham-cassidy-
proposal-puts-medicaid-coverage-at-risk/.
In addition, the Graham-Cassidy-Heller-Johnson healthcare proposal
allows states to require beneficiaries to re-certify their eligibility
for Medicaid every 6 months.\6\ This requirement would be overly
burdensome. Individual's with Parkinson's who are on Medicaid due to
disability do not one day lose their disability. The disability status
is permanent. Requiring recertification with such frequency is cruel
and appears to be a mechanism to dissuade people from accessing this
important program.
---------------------------------------------------------------------------
\6\ Amendment to H.R. 1628, 115th Congress (2017).
Lastly, Senator Cassidy has stated, ``funds are quite unequally
distributed. Where you live should not determine how healthy you are.''
\7\ As such, the funding formulary should not be skewed in a manner
that would create inequity by increasing funding for states whose
Senators have expressed concern regarding the Graham-Cassidy-Heller-
Johnson healthcare proposal. Funding determinations should be made in a
manner that best serve healthcare consumers and are most likely to
provide access to affordable, quality healthcare coverage for the
Parkinson's community and all Americans.
---------------------------------------------------------------------------
\7\ Sarah Kliff, ``Cassidy makes the case for his plan to repeal
Obamacare,'' Vox, September 15, 2017, https://www.vox.com/policy-and-
politics/2017/9/15/16316852/cassidy-plan-to-repeal-obamacare.
In conclusion, we thank the Senate Committee on Finance for providing
The Michael J. Fox Foundation for Parkinson's Research and the between
750,000 and 1 million patients living with Parkinson's disease the
opportunity to share with you our thoughts regarding the Graham-
Cassidy-
Heller-Johnson healthcare proposal. We urge the committee to consider
our concerns regarding various provisions of the Graham-Cassidy-Heller-
---------------------------------------------------------------------------
Johnson healthcare proposal.
______
Michigan Developmental Disabilities Council
Michigan Department of Health and Human Services
Nick Lyon, Director
320 S. Walnut Street
Lansing, Michigan 48913
(517) 335-3158 Voice
(517) 335-2751 Fax
https://www.michigan.gov/
Rick Snyder
Governor
Paul Palmer
Chairperson
Vendella M. Collins
Executive Director
September 22, 2017
U.S. Senate
Committee on Finance
Dirksen Senate Office Bldg.
Washington, DC 20510-6200
Subject: Hearing to consider the Graham-Cassidy-Heller-Johnson
proposal, September 25, 2017
Dear Chairman Hatch:
Michigan Developmental Disabilities Council respectfully submits the
following written testimony expressing our strong opposition to the
Graham-Cassidy-Heller-Johnson proposal to repeal and replace the
Affordable Care Act and reshape the way Medicaid funds will be
distributed to the states.
The council's opposition to this legislation dives deeply into the
negative consequences this legislation will have on people with
disabilities (PWDs) should it be signed into law. For PWDs, Medicaid is
far more than just a health plan, it is a vital lifeline of support and
services needed to navigate the daily life needs of the individual. It
is not an exaggeration or embellishment that we have termed Medicaid a
``lifeline,'' for some, it is their only source of supports and
services they have. If any reduction of these services transpire due to
the application of this legislation, it will, not it may, mean life and
death decisions will have to be made regarding what provisions will be
available to societies most vulnerable citizens.
It is most appropriate to separate policy from politics and view this
issue from an elevated perspective that allows comprehensive evaluation
based on facts. Examining one of the core components this proposal,
repealing and replacing the Affordable Care Act (ACA), we need to
critically explore how repealing components of this act will negatively
impact PWDs.
Fact: not all people with disabilities are on Medicaid or Medicare.
PWDs are also enrolled in private healthcare coverage. Prior to the
enactment of the ACA, many people were denied coverage based on pre-
existing conditions or reaching annual/lifetime limits. The ACA made
these actions illegal and allowed many PWDs to enroll into healthcare
coverage.
Fact: the ACA made it possible for those with private insurance to
access habilitative and rehabilitative services. Without such services,
many may have ended up in a nursing facility creating an even greater
hardship on the Medicaid program.
Fact: the disability population is the fastest growing minority
population in the country. It has no borders. It includes individuals
of all ages, cultures, and genders. It can affect any person at any
time. Repealing the ACA will increase the number of PWDs who are
uninsured and who will be unable to obtain private healthcare coverage.
Fact: age is one of the leading causes of disabilities in America.
As a nation, we are rapidly gaining in age, henceforth, there will be a
much greater need for access to healthcare, not less.
Fact: uncompensated care rates for the major hospitals in Michigan
was reduced by nearly 50% due to the increase in people having
healthcare coverage. Repealing the ACA will INCREASE hospital
expenditures and cost due to an increase in uncompensated care. This
will also impact private insurers who will raise their rates to help
cover the added cost, creating a cascade of out of control healthcare
coverage costs.
An additional element of the Graham-Cassidy-Heller-Johnson proposal
that will create great hardship for people with disabilities is the
dismantling of the current Medicaid funding model and transitioning
into block granting states under the moniker of ``state flexibility.''
To its credit, Michigan provides PWDs with a level of benefits that is
above the minimum requirements established by Center for Medicare
Medicaid Services (CMS). This is accomplished by the state being able
to work with CMS and the federal government in establishing programs
that promote better health, increased self-sustainability, decreased
healthcare costs, and provide better supports and services that enable
people to live on their own. That is true flexibility. If block grants
are imposed on individual states (which will result in reduced funding
and flexibility), it is highly likely that PWDs will experience a
substantial reduction in the services they need to stay independent.
Flexibility means the ability to give and take; not being rigid, the
capacity to work together. Block granting does not encourage state
flexibility but rather fosters a state's inability to work collectively
with our federal partners. If flexibility is truly the desired outcome,
increased 1115 demonstration projects should be the focus and more
importantly, how the states and CMS can work more closely together to
address the healthcare and support crisis facing our country.
As mentioned, Michigan does a fairly good job in ensuring PWDs have
access to the services most needed. Even with these standards in place,
we are continually running into insurmountable hurdles that create
hardships for PWDs, seniors and their families.
Fact: Michigan has a shortage of over 2,000 direct support workers
who help PWDs and seniors with their daily living needs. If state
Medicaid funding is reduced, this shortage will be substantially
increased reducing staff numbers to an already short supply.
Fact: there are no states that expanded Medicaid to people below
138% of the federal poverty level with budget surpluses large enough to
cover the losses in federal Medicaid revenue should block-granting be
implemented. This will substantially increase a state's uninsured rate
as well as place greater hardships on state's limited resources.
Fact: Michigan has over 600,000 lives covered under Healthy
Michigan. This means that over 6% of Michigan's population is below
138% of the federal poverty level. This figure does not include those
who were/are eligible for traditional Medicare or Medicaid. PWDs who
were not covered under traditional Medicaid will be removed from
healthcare coverage.
Fact: The United States is in the midst of a substance use crisis
related to opiate abuse. Reducing Medicaid funding to states that could
be used to help fight substance use disorders through continued
coverage will only exasperate this problem.
Even though the above facts are Michigan specific, it is easily argued
that many other states face similar problematic issues that federal
Medicaid block granting will create or intensify.
Lastly, it is extremely important to realize that in 2014 nearly two-
thirds of Medicaid funding is used for PWDs and seniors. Over one-third
of Medicaid beneficiaries are people who receive Social Security Income
(SSI). The Medicaid reduction proposed through block granting (reducing
funding going to states in excess of hundreds of billions of dollars)
targets PWDs and seniors, period. Acknowledging that PWDs and seniors
are the greatest utilizers of the supports and services provided by
Medicaid, it only stands to reason that these cuts will impact the most
vulnerable of our society the most. Reiterating the fact that
disabilities know no boundaries, these proposed cuts will create an
widespread reduction of available supports and services that will only
be amplified by the continuance of the increasing medium age and the
level of disabilities experienced by the people in this great country.
Should you have any questions or concerns regarding our opposition to
the Graham-Cassidy-Heller-Johnson proposal, please feel free to contact
our Public Policy Analyst, Brett Williams at 517-284-7289.
Sincerely,
Paul Palmer
Michigan Developmental Disabilities Council-Chairperson
______
NARAL Pro-Choice America
1156 15th Street, NW, Suite 700
Washington, DC 20005
https://www.prochoiceamerica.org/
202-973-3000
202-973-3070 fax
September 26, 2017
The Honorable Orrin Hatch The Honorable Ron Wyden
Chairman Ranking Member
U.S. Senate U.S. Senate
Committee on Finance Committee on Finance
RE: Written statement for the record, September 25, 2017 Senate Finance
Committee hearing to consider the Graham-Cassidy-Heller-Johnson
proposal
Dear Chairman Hatch and Ranking Member Wyden:
NARAL Pro-Choice America is pleased to submit this written statement
for the record for the September 25, 2017 Hearing to Consider the
Graham-Cassidy-Heller-Johnson (Graham-Cassidy) Proposal before the
Senate Finance Committee. For the reasons outlined below, NARAL Pro
Choice America strongly opposes the Graham-Cassidy-Heller-Johnson
proposal.
NARAL is a national advocacy organization dedicated since 1969 to
supporting and protecting, as a fundamental right and value, a woman's
freedom to make personal decisions regarding the full range of
reproductive choices, including preventing unintended pregnancy,
bearing healthy children, and choosing legal abortion. Through
education, organizing, and influencing public policy, NARAL and our 1.2
million member activists work to guarantee every woman this right,
regardless of her income, where she obtains her health-care coverage,
or her zip code.
NARAL is deeply concerned by the Graham-Cassidy proposal's impact on
women and families across the country. By ensuring coverage and
affordability of maternity care, family-planning services, and other
reproductive-health services, the Affordable Care Act (ACA) represented
a major step forward. Additionally, Planned Parenthood is an integral
part of the public-health system, serving 2.5 million patients each
year. Dismantling the ACA and defunding Planned Parenthood would be
nothing short of devastating for public health. Yet, the Graham-Cassidy
measure would do just that--from dismantling Medicaid as we know it to
allowing states to waive critical consumer protections and prohibiting
women from purchasing comprehensive coverage, including for abortion
care. This bill would upend the entire health-care system and
jeopardize access to vital health-care coverage across the country.
Under the devastating funding cuts and Medicaid restructuring in the
Graham-
Cassidy proposal, millions of Americans\1\ will lose health-care
coverage altogether. Furthermore, those who remain covered will lose
critical protections provided under the ACA. Women are among those with
the most at stake. For example, Graham-
Cassidy provides an avenue for states to permit insurers to ignore
outright coverage requirements for essential health benefits and
preventive care--including maternity care and no-copay birth control.
Prior to the ACA, only 18 states required insurers to cover or offer
coverage for maternity care in individual or small group insurance, but
thanks to the ACA, women in all 50 states and the District of Columbia
are guaranteed this coverage in their marketplaces. Under Graham-
Cassidy, women desiring this coverage would be forced to pay for an
insurance rider--a separate policy to cover maternity care--which could
cost more than $1,000 per month (on top of the premium a woman is
already paying for her ``comprehensive'' coverage).\2\ Additionally
62.4 million women now have contraceptive coverage with no additional
out-of-pocket cost.\3\ Women are saving $1.4 billion per year, just on
the birth-control pill.\4\
---------------------------------------------------------------------------
\1\ Congressional Budget Office, ``Preliminary Analysis of
Legislation That Would Replace Subsidies for Health Care With Block
Grants'' (September 2017), at https://www.cbo.gov/system/files/115th-
congress-2017-2018/costestimate/53126-health.pdf.
\2\ Congressional Budget Office, ``Cost Estimate of H.R. 1628,
American Health Care Act of 2017, as Passed by the House of
Representatives on May 4, 2017'' (May 24, 2017), at https://
www.cbo.gov/system/files/115th-congress-2017-2018/costestimate/
hr1628aspassed.pdf.
\3\ National Women's Law Center, ``New Data Estimates 62.4 Million
Women Have Coverage of Birth Control Without Out-of-Pocket Costs''
(September 2017), at https://nwlc.org/wp-content/uploads/2017/09/New-
Preventive-Services-Estimates-3.pdf.
\4\ Nora Becker and Daniel Polsky, ``Women Saw Large Decrease in
Out of Pocket Spending for Contraceptives After ACA Mandate Removed
Cost Sharing,'' 34 Health Affairs 1204 (2015).
The Graham-Cassidy proposal also mounts an unprecedented attack on
abortion access. In the short term, the bill prohibits women and small
businesses who receive tax credits from purchasing insurance plans that
cover abortion care. Once the tax credits cease, the abortion coverage
restrictions continue: the bill also funnels state grants through a
children's health insurance fund that bans abortion coverage except in
the most narrow of circumstances. The proposal also prohibits women
from using their own health savings accounts to pay for plans that
cover abortion services. The end result--and ultimate goal--is to
effectively eliminate abortion coverage from the private insurance
---------------------------------------------------------------------------
market altogether.
In sum, the Graham-Cassidy proposal would be catastrophic for women and
families, whether they lose coverage altogether because of Medicaid
cuts, become priced out of the market, maintain a policy but do not
have the comprehensive coverage and protections they need most, or lose
access to their trusted Planned Parenthood provider. For these reasons,
NARAL Pro Choice America strongly opposes the Graham-Cassidy proposal
and urges senators to work towards policies that expand access to care,
rather than taking it away.
Thank you for your consideration.
Respectfully,
Ilyse Hogue
President
______
National Association of School Nurses (NASN)
1100 Wayne Avenue, Suite 925
Silver Spring, Maryland 20910
866-627-6767 (phone)
301-585-1791 (fax)
https://www.nasn.org/home
October 5, 2017
Senator Orrin Hatch Senator Ron Wyden
Chairman Ranking Member
U.S. Senate U.S. Senate
Committee on Finance Committee on Finance
Washington, DC 20510 Washington, DC 20510
Dear Senators Hatch and Wyden:
The National Association of School Nurses (NASN) opposes the Graham-
Cassidy or any version of healthcare legislation that contains
provisions that either fund Medicaid via block grants or has a per
capita cap on Medicaid.
NASN represents over 16,000 school nurses across the country working to
optimize the academic success of student sure they are healthy, and
safe, and ready to learn. Children today face more chronic and complex
health conditions than ever before. Children are the currency of our
future and as such, must have their health needs met throughout the
day, including during school hours.
Schools are part of the safety net for children and Medicaid plays a
significant role, particularly in funding vital medical services for
children in special education under the Individuals with Disabilities
Education Act (IDEA) and for those students in general education who
are eligible for Medicaid. Medicaid reimbursement to schools for the
healthcare of children generates between $4-5 billion a year or
approximately 1 percent of all Medicaid funds.
The proposed Graham-Cassidy legislation will impact the ability of
students with disabilities and students in poverty to receive critical
school health services that enable them to engage in learning. This
includes services provided by the school nurse, such as vision and
hearing screenings and management for students with diabetes and
asthma. The Early and Periodic Screening, Diagnostic, and Treatment
(EPSDT) Programs are funded by Medicaid and ensure that children
receive the preventive health check-ups and early intervention needed
to hold chronic diseases at bay. Additional services funded by Medicaid
are mental and behavioral health, speech language pathology,
occupational and physical therapy, and essential equipment for students
including wheelchairs and hearing aids. Schools utilize Medicaid
funding to offset the cost of these professional healthcare services,
thereby preserving education dollars for student education.
Medicaid covers nearly 36 million children. While children are
approximately 44 percent of Medicaid beneficiaries, they comprise only
19 percent of the cost of cost of Medicaid. Chronic health conditions
and barriers that limit access to healthcare disproportionately affect
lower income children. Children must be healthy and safe to be ready to
learn.
NASN has long supported Medicaid, CHIP and other programs that help all
children to be covered by and have access to quality, affordable health
insurance. NASN opposes all efforts that weaken those supports for
children, most especially per capita caps or block grants to Medicaid.
Sincerely,
Nina Fekaris
President
______
National Council for Behavioral Health
1400 K Street, NW, Suite 400
Washington, DC 20005
202-684-7457
https://www.thenationalcouncil.org/
Statement for the Record from Linda Rosenberg, President and CEO
Last week, the ugly health care debate reared its head again on Capitol
Hill with the introduction of a new bill by Senators Graham (R-SC),
Cassidy (R-LA), Heller (R-NV) and Johnson (R-WI) to drastically cut
Medicaid and other federal health funds to states.
This bill may go by a different name than previous efforts to reshape
the health care system, but it maintains and even worsens the
devastating provisions from those bills that led to a massive
constituent outcry earlier this summer. It's the same pig with
different lipstick.
Like past versions of the Senate health bill, the new legislation would
result in catastrophic outcomes for the millions of Americans living
with addiction or mental illness.
It caps federal Medicaid spending at a rate designed to grow
more slowly than inflation, shifting costs to states and forcing them
into difficult decisions about which populations and services to cut.
It repeals the Medicaid expansion, taking away states' number
one tool in fighting the opioid epidemic. Medicaid pays for 35-50% of
all medication-assisted opioid treatment in states that have been hit
hardest by the opioid epidemic, like Alaska, Ohio, and West Virginia.
It eliminates subsidies that keep insurance affordable,
stripping people with complex conditions like addiction or mental
illness of the support they need to afford coverage.
It sets states up for future budget shortfalls, replacing the
Medicaid expansion and insurance subsidies with a block grant that
would not grow in response to increased enrollment or costs.
It allows states to opt out of pre-existing coverage protections
and essential health benefits, returning us to the days when people
with addiction or mental illness could not get coverage for their
conditions.
The results for Americans with addiction or mental illness are stark:
massive coverage losses and reduced access to lifesaving treatment.
The Senate Health, Education, Labor, and Pensions Committee has spent
the past month working on bipartisan legislation that would stabilize
the health insurance market and create a better health care system.
With legislation from these efforts expected soon, now is not the time
to renew the failed partisan effort that slashes billions of Medicaid
dollars from state budgets, costing hundreds of thousands of lives.
We implore Senators to focus on the bipartisan efforts underway and
ignore this politically driven effort to rush a devastating bill
through the Senate without time for debate and consideration of the
impact on states and constituents.
Now is the time to unite across party lines, stand up for what is right
and ensure that the millions of Americans facing addiction and mental
illness continue to get the care they deserve.
* * *
The National Council for Behavioral Health is the unifying voice of
America's health care organizations that deliver mental health and
addictions treatment and services. Together with our 2,900 member
organizations serving over 10 million adults, children and families
living with mental illness and addictions, the National Council is
committed to all Americans having access to comprehensive, high quality
care that afford every opportunity for recovery. The National Council
helped introduce Mental Health First Aid USA and more than 1 million
Americans have been trained.
______
National Disability Rights Network (NDRN)
Dear Chairman Hatch, Ranking Member Wyden, and Honorable Senate Finance
Committee Members:
On behalf of the National Disability Rights Network (NDRN) and the
nationwide network of Protection and Advocacy (P&A) and Client
Assistance Program (CAP) agencies, we urge you to reject the Graham-
Cassidy-Heller-Johnson bill, which will have devastating effects on the
over 57 million people with disabilities in this country.
NDRN is the non-profit membership organization for the federally
mandated P&A and CAP agencies for individuals with disabilities. The
P&A and CAP agencies were established by the United States Congress to
protect the rights of people with disabilities and their families
through legal support, advocacy, referral, and education. P&As and CAPs
are in all 50 states, the District of Columbia, Puerto Rico, and the
U.S. Territories (American Samoa, Guam, Northern Mariana Islands, and
the U.S. Virgin Islands), and there is a P&A and CAP affiliated with
the Native American Consortium which includes the Hopi, Navajo and San
Juan Southern Paiute Nations in the Four Corners region of the
Southwest. Collectively, the 57 P&A and CAP agencies are the largest
provider of legally based advocacy services to people with disabilities
in the United States.
Every day, P&A and CAP agencies seek to improve the lives of people
with disabilities to be more fully integrated into the community, and
an important aspect of achieving that goal is the ability to receive
services through the Medicaid program. Whether it is an individual with
a disability trying to live in the community, an individual trying to
get a job at a competitive wage and in an integrated setting, or
receive a quality education, the Medicaid program plays a critical role
in achieving that goal. As we have stated concerning multiple proposals
considered by the Senate, we cannot overstate the danger facing the
millions of adults and children with disabilities if the proposal's
Medicaid provisions are adopted. The proposal's imposition of a per
capita cap and the elimination of the adult Medicaid expansion would
decimate a program that has provided essential healthcare and long term
services and supports to millions of adults and children with
disabilities for decades. We are also extremely concerned about the
changes proposed to the private individual health insurance market and
the tax credits that currently assist low-income individuals, including
individuals with disabilities, to purchase insurance.
Some 10 million people with disabilities and, often, their families,
depend on the critical services that Medicaid provides for their
health, functioning, independence, and well-being. For decades, the
disability community and bipartisan Congressional leaders have worked
together to ensure that people with disabilities of all ages have
access to home- and community-based services that allow them to live,
work, go to school, and participate in their communities instead of
passing their days in institutions. Medicaid has been a key driver of
innovations in cost-effective community-based care, and is now the
primary program covering home and community-based services (HCBS) in
the United States. Older adults and people with disabilities rely on
Medicaid for nursing and personal care services, specialized therapies,
intensive mental health services, special education services, and other
needed services that are unavailable through private insurance.
Like other proposals considered by the Senate, this legislation upends
those critical supports. Per capita caps--which have nothing to do with
the Affordable Care Act--would radically restructure the financing of
the traditional Medicaid program and divorce the federal contribution
from the actual costs of meeting people's health care needs. Caps are
designed solely to cut federal Medicaid support to states, ending a
decades-long bipartisan state/federal partnership to improve
opportunities and outcomes for of our most vulnerable. Slashing federal
funds will instigate state budget crises that stifle the planning and
upfront investments required to create more efficient care systems.
Caps will force states to cut services and eligibility that put the
lives, health, and independence of people with disabilities at
significant risk. In fact, because HCBS (including waivers) are
optional Medicaid services, they will likely be among the first targets
when states are addressing budgetary shortfalls. The structure of this
legislation's cap--like the structure in previous bills--exacerbates
the cuts after it reduces the growth rate in 2025. The Congressional
Budget Office score on similar per capita cap proposals showed cuts to
federal support by $756-834 billion by 2026, with steeper cuts the
following years, amounting to a draconian 35% cut by 2036. Such caps
would cause tens of millions of Americans to lose Medicaid coverage.
Targeted carve outs and targeted funding pots included in this
legislation are a mockery in comparison to the scope of these cuts. For
example, this legislation offers a 4-year $8 billion dollar
demonstration to expand Medicaid home and community-based services--
which is not even half of the $19 billion cut to the Community First
Choice option that eight states have implemented to expand access to
necessary in-home services for people with disabilities.\1\ All
individuals on Medicaid will be significantly impacted by cuts of this
magnitude, despite any limited, temporary demonstration funding or
restricted funding carve out for a fraction of the children with
disabilities that Medicaid supports. Throwing billions in extra
temporary funds cannot curb, and is disingenuous by hiding, the
inevitable, long-term loss of critical Medicaid services that people
with disabilities will face as a result of per capita caps.
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\1\ Congressional Budget Office, ``Cost Estimate for H.R. 1628,''
33 (June 26, 2017).
In addition, this legislation ends the Medicaid Expansion and the
current tax credits and cost sharing reductions that assist low income
individuals in purchasing health insurance by 2020, replacing this
assistance with a block grant that would reduce funding by $239 billion
by 2026. After 2026, there would be no federal funding to help the
millions of Americans, including millions with disabilities, who rely
on Medicaid Expansion and Marketplace coverage to access health care.
These are people who previously fell through the cracks in our health
care system. This includes individuals with disabilities in a mandatory
waiting period before their Medicare coverage begins and millions of
people with a behavioral health condition who previously had no pathway
to steady coverage. Others who gained coverage through the Medicaid
expansion also includes millions of family caregivers whose full time
uncompensated job is caring for a child or older adult with a
disability and hundreds of thousands of low wage direct care workers
who serve people with disabilities. Medicaid expansion helps stabilize
our long-term care support networks by keeping caregivers healthy and
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reducing turnover.
Likewise, Marketplace coverage ensures that people with disabilities
can buy comprehensive and affordable health care and have equal access
to much needed health care including examinations, therapies to regain
abilities after an illness or injury, and affordable medications. We
have serious concerns about this legislation's private market
provisions, including the state waiver authority to eliminate
protections for people with preexisting conditions (including people
with disabilities), older adults, and people who need access to
essential health benefits. The nondiscrimination provisions and health
insurance reforms, the expanded access to long-term supports and
services, and the expanded availability of comprehensive and affordable
health care have helped many more individuals with disabilities live in
the community and be successful in school and the work place. No longer
do individuals with disabilities and their families have to make
horrifying choices about whether to pay their mortgage, declare
bankruptcy, or choose between buying groceries and paying for needed
medications.
In short, this legislation makes health insurance unaffordable for
millions of people, particularly people with disabilities, older
adults, and those with chronic health conditions. The cumulative effect
of the private insurance and Medicaid proposals will leave people with
disabilities without care and without choices, caught between Medicaid
cuts, unaffordable private insurance, and limited high risk pools. The
CBO estimated that Affordable Care Act (ACA) repeal without a
replacement would cause 32 million people to lose insurance. This
legislation would be even worse, as it effectively repeals all the ACA
coverage expansions after 2026, and also implements per capita caps on
the rest of Medicaid that will lead to additional enrollment cuts.
Finally, we are extremely disappointed that the proposal has not been
considered under regular order and in fact usurped an active bipartisan
effort to bolster Marketplace coverage. The Senate has a longstanding
history of deliberating policy proposals through transparent processes,
including public hearings, open comment periods on discussion drafts,
and multi-stakeholder meetings. We are particularly concerned that
Senators are expressing support of this proposal without a
Congressional Budget Office (CBO) score that thoroughly examines the
short and long-term financial and coverage impacts. The complete
restructuring proposed for the individual private insurance market is
likely to have repercussions on coverage that prior CBO estimates do
not take into account. We ask all Senators to reject this proposal and
instead engage in the process of regular order and work toward
bipartisan solutions that ensure that all adults and children with
disabilities have access to the healthcare they need.
______
National Health Council (NHC)
1730 M Street, NW, Suite 500
Washington, DC 20036
On behalf of all people with chronic diseases and disabilities and
their family caregivers, the National Health Council (NHC) submits this
statement for the record to oppose the amendment to the American Health
Care Act (AHCA) proposed by Senators Lindsey Graham, Bill Cassidy, Dean
Heller, and Ron Johnson, just as we oppose the underlying AHCA. Both
pieces of legislation will harm those with pre-
existing conditions.
Founded in 1920, the NHC is the only organization that brings together
all segments of the health community to provide a united voice for the
more than 133 million people with chronic diseases and disabilities and
their family caregivers. Made up of more than 100 national health
related organizations and businesses, the NHC's core membership
includes the nation's leading patient advocacy organizations, which
control its governance and policy-making process. Other members include
professional and membership associations, nonprofit organizations with
an interest in health, and representatives from the pharmaceutical,
generic drug, health insurance, device, biotechnology, and
communications industries.
The amendment being considered today falls well short of addressing the
many concerns the patient advocacy community has continually raised
with previous bills such as the AHCA and the Better Care Reconciliation
Act (BCRA). It contains many of the same harmful provisions that will
negatively impact people with pre-existing medical conditions.
First, we are deeply concerned about cuts in funding for and removal of
the requirement for subsidies to help those who cannot afford their
insurance. In addition to providing assistance to help lower-income and
middle-class Americans afford coverage, premium subsidies have had the
greatest impact in encouraging people to enroll in insurance, which
helps create a more balanced and stable risk pool. Likewise, the cost-
sharing reduction assistance greatly helps lower-
income people afford out-of-pocket expenses such as deductibles,
copays, and coinsurance. The repeal of these programs, reduction in
funding, and lack of requirement that funding allocated to states be
used to help people afford their health care is incredibly troublesome.
We are also concerned that the funding is not guaranteed beyond 2026.
We also are adamantly opposed to the expansion of states' ability to
waive key patient and consumer protections. Graham-Cassidy allows any
state that receives funding to waive protections such as the
requirement that premiums cannot vary based on health status as well as
essential health benefit (EHB) requirements. These actions would
combine to completely undermine pre-existing condition protections for
individuals with chronic conditions, as the cost of coverage could
become prohibitively expensive or plans could exclude coverage for
specific conditions and treatments. Waiving EHB requirements is further
detrimental to people with chronic health conditions, both physical and
mental health, and those who require costly care, as it will expand the
ability to impose lifetime and annual limits on coverage and lessen the
cap on out-of-pocket expenses. These protections only apply to EHBs, so
this proposal will essentially open the door for discriminatory plan
design elements to return to the insurance market. While the proposal
does require that states applying for a waiver include a description of
``how the State intends to maintain access to adequate and affordable
health insurance coverage for individuals with pre-existing
conditions,'' it is unclear how this standard will be applied and
enforced.
Finally, the proposed amendment's cuts and changes to the Medicaid
program are simply unacceptable to the patient community. Graham-
Cassidy follows the same path as previous efforts to repeal and replace
the Affordable Care Act (ACA) by ending the expansion of Medicaid and
fundamentally reforming it by limiting long-term funding to the
program. The combination of these two efforts will result in states
making drastic changes to their program, which will result in reduced
access to care for the nation's most vulnerable populations.
In addition to the substantive concerns with the legislation, the NHC
is deeply troubled that such an impactful bill may be voted on without
a full analysis from the nonpartisan Congressional Budget Office (CBO).
CBO has indicated that they will not be able to provide estimates on
how many Americans will lose coverage or how the legislation will
impact premiums or deductibles. However, independent studies have
indicated that the impacts will be similar to the AHCA and BCRA,
causing millions to lose coverage and deductibles and other out-of-
pocket expenses to greatly increase. These impacts were a main reason
why the patient-advocacy community opposed these bills, and we would
welcome the opportunity to have a greater understanding of the impacts
before the legislation is considered. Further, the implementation
timeline outlined in the bill is incredibly unfeasible for states and
the federal government to completely transition to a new health
insurance marketplace. It will create tremendous uncertainty and has
the likelihood of destabilizing the market for the foreseeable future.
While we urge the Senate to reject Graham-Cassidy, we understand that
the ACA has flaws that must be addressed by Congress. We were heartened
by the bipartisan effort being spearheaded by Senators Alexander and
Murray. Through hearings held in the Committee on Health, Education,
Labor, and Pensions, we heard from many state regulators and governors
of both parties who offered solutions to help stabilize the insurance
market. We encourage the Finance Committee to join in these efforts to
address issues within its jurisdiction to develop bipartisan solutions
to these complex issues. To this end, the NHC has developed a set of
recommendations.\1\ At a high level, we recommend that Congress:
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\1\ http://www.nationalhealthcouncil.org/sites/default/files/
NHC%20ACA%20Stabilization%
201-Pager%20V5.pdf
Assure funding for cost-sharing reductions;
Establish a stability fund;
Support navigator programs;
Maintain financial assistance;
Maintain coverage of essential health benefits, including the
standard that benefits typical of an employer group health plan be
required in the individual market;
Strengthen and fund outreach and marketing; and
Monitor and address bare or limited-choice counties.
As the Senate Finance Committee examines the proposal introduced by
Senators Graham, Cassidy, Heller, and Johnson, we encourage the
Congress to reject this proposal and consider the impact it will have
on every American. Most importantly, please consider how it will
negatively impact the 133 million Americans with chronic diseases and
disabilities and their family caregivers.
______
National Health Law Program
1444 I Street, NW, Suite 1105
Washington, DC 20005
(202) 289-7661
The National Health Law Program is a national, non-profit organization
that protects and advances the health rights of low income and
underserved individuals. We strongly oppose the Graham-Cassidy-Heller-
Johnson amendment (``Graham-
Cassidy'') as its substance would decimate the Medicaid program and
throw the country's health care system into chaos. Further, we are
extremely concerned about the lack of transparency regarding
consideration of the Graham-Cassidy proposal. We strongly urge the
Senate to ensure that any effort to restructure or change Medicaid--a
program whose financing structures have been in place for over 50
years--and the Affordable Care Act not move forward without formal
hearings and mark-ups and a full score from the Congressional Budget
Office regarding both impact on the deficit and coverage.
Medicaid is a vital program not only to the 74 million individuals
enrolled at any point in time but also to health care providers, our
communities, and states. Moreover, studies have shown that the Medicaid
program has a positive economic effect for states and the influx of
federal funds magnifies this impact. Medicaid funds not only directly
support tens of thousands of health care providers and their staff
throughout the country but the influx of federal dollars results in a
multiplier effect indirectly affecting other businesses and industries
as well.\1\ The Graham-Cassidy proposal would effectively repeal
Medicaid expansion (not even allowing states to continue covering
expansion enrollees at a regular Medicaid match) and convert Medicaid
into a per capita cap coupled with billions of dollars in cuts. Every
state will be impacted and all will be forced to make deep cuts in
services and eligibility. Any legislation that fundamentally
restructures Medicaid will have profound effects not only on the 74
million individuals currently covered, but also on the hospitals,
community health centers, managed care plans, nursing facilities, group
homes and other providers that serve them, as well as the state and
counties and communities in which they live.
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\1\ Kaiser Family Foundation, ``Medicaid Financing: How Does it
Work and What are the Implications?'', (May 20, 2015), available at
http://kff.org/medicaid/issue-brief/medicaid-financing-how-does-it-
work-and-what-are-the-implications/.
We also strongly oppose the changes the Graham-Cassidy proposal makes
to the Affordable Care Act and the marketplaces. States would receive
fixed funding and virtually unlimited flexibility to determine how to
spend it. States would not be required to provide financial assistance
to low-income individuals as the proposal repeals the ACA's tax credits
and cost-sharing reductions. The one hearing scheduled in the Senate
Finance Committee does not provide the transparency that changes of
this magnitude deserve. Nor could it be considered ``regular order'' to
move ahead without a full score from the Congressional Budget Office
(CBO), as the Committees and the full Senate propose to do. The
implications of the Graham-Cassidy proposal restructuring one-sixth of
the economy of the country and its dramatic impact on low-income
individuals, providers, states and counties, and for the integrity of
the Medicaid program are too significant to rush the legislative
---------------------------------------------------------------------------
process.
If the Senate takes up this legislation without undertaking the
considered steps of ``regular order'' and without awaiting a full score
from the Congressional Budget Office, the Senate will abdicate its
basic responsibility to the American people. We strongly urge the
Senate to return to the regular order that recently produced a bi-
partisan bill to reauthorize the Children's Health Insurance Program
and that was working on bipartisan solutions to stabilize the
marketplaces.
We have specific concerns about the impact of the Graham-Cassidy
proposal about Medicaid, women's health, and people with disabilities
that we outline below.
Medicaid
Octavio is a sweet 8-year-old boy from Texas. He likes to swim, hike,
bowl, and visit the zoo. He has autism and receives SSI Medicaid for
his care. At age 2, he said only three words, and due to severe oral-
motor and sensory issues, he could not eat solid food and still drank
from a baby bottle. Thanks to speech and occupational therapies,
Octavio began speaking, drinking from a cup, and eating regular food.
Although he has made significant progress, Octavio is still
developmentally delayed and needs many more years of therapy to become
an independent adult. His mother, Rosanna stays at home to care for
him. She says, ``I am very concerned about Republican proposals to cut,
cap, or block grant Medicaid. My son relies on Medicaid to cover his
speech, occupational, and physical therapies as well as his doctor and
dental visits. As it is, some doctors and therapists have stopped
taking Medicaid because of red tape and low reimbursements rates.
Further cuts and caps will destroy the program.''
1. Per Capita Cap (PCC). Since 1965, Medicaid has operated as a
federal-state partnership where states receive on average 63% of the
costs of Medicaid from the federal government. The federal share is
based on actual costs of providing services, and lower income states
receive more federal funding. Graham-
Cassidy limits the federal contribution to states, based on a state's
historical expenditures inflated at a rate projected to be less than
the yearly growth of Medicaid health care costs.\2\ Beginning January
1, 2020, funding for state Medicaid programs will shrink over time,
resulting in states cutting coverage and services for all
beneficiaries. In addition, starting in 2025, states would be limited
to an even lower growth rate than in the initial PCC years. Graham-
Cassidy also imposes a penalty on states that spend above the national
mean, starting in 2020 (2 years earlier than BCRA). This penalty would
be imposed even if a state spends more because care is more costly due
to geography or other factors or because enrollees are older or sicker
than in another state. If a state spends 25% more than the national
mean for a particular eligibility group (e.g., seniors or people with
disabilities), it would lose .5-2% of its aggregate cap amount for the
applicable group for that year unless the state is a ``low density''
state (less than 15 individuals per square mile). We oppose converting
Medicaid into per capita caps and strongly believe Medicaid's current
financing structure must remain in place.
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\2\ Graham-Cassidy's growth rate from the state's base year through
2019 is the medical component of the Consumer Price Index (CPI-M). For
2019-2025, the growth rate would be CPI-M plus 1% for elderly enrollees
and enrollees with disabilities and CPI-M for adults and children.
Beginning in 2025, the growth rate would lower to the ``regular'' CPI
which grows even slower than CPI-M and does not include long term care
costs.
2. Medicaid Expansion. Graham-Cassidy goes a step further than
prior Senate bills by reducing the FMAP to 0% for any state that covers
Medicaid expansion enrollees after 2020 (except Native Americans who
meet certain ``grandfathering'' requirements). Experts estimate that
1.3 million individuals covered in the Medicaid expansion have a
serious mental health diagnosis. Medicaid expansion has been associated
with reducing significant unmet mental health care needs. By repealing
Medicaid expansion, Graham Cassidy turns back the clock on this
progress. Even if a state wanted to continue covering Medicaid
expansion enrollees, it could not get any federal funding and would
have to pay 100% of the costs. Graham-Cassidy creates a new block grant
for states to help pay for health coverage for consumers who would have
been covered by Medicaid expansion, as well as those who would have
received tax credits and cost-sharing reductions, among other factors.
But the block grant funding is set at 17% less than current funding. We
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oppose repealing the Medicaid Expansion option for states.
3. Shorter Eligibility Periods for Medicaid Expansion Enrollees.
While states can continue Medicaid Expansion through December 31, 2019
with a 90% federal match, Graham-Cassidy allows states to require those
in the Medicaid expansion population to submit eligibility renewal
paperwork every six months just to stay on Medicaid, beginning October
1, 2017. This will certainly result in more eligible enrollees losing
their Medicaid coverage. We oppose requirements for additional
documentation due to shorter eligibility periods.
4. Work Requirements. Graham-Cassidy allows states to impose work
requirements on people who are not disabled, elderly, or pregnant
Medicaid enrollees. Currently, nearly 8 in 10 Medicaid enrollees are
part of a working family. Another 14% of Medicaid enrollees are
currently looking for work. Yet, Graham-Cassidy would allow states to
require work as a condition of eligibility, including enrollees who are
caring for a parent or spouse and both parents in a two-parent
household. Individuals receiving mental health or substance use
disorder services who are eligible through Medicaid expansion (rather
than a disability category) would be required to work as a condition of
receiving treatment, which could undermine their progress and recovery.
Medicaid coverage makes it easier to find and sustain work and should
not be denied to those who need care before being able to work. We
oppose work requirements in Medicaid.
5. Block Grant for Certain Populations. In addition to requiring
all states to operate within fixed caps, Graham-Cassidy also gives
states the option to operate part of Medicaid program as a block grant
as opposed to a PCC for people who are not elderly, disabled, pregnant
adults. States would be locked in for a 5-year period, and the growth
rate would be lower than the initial per capita cap growth rate
(although by 2025, both the PCC and block grant growth rates would be
the same). We oppose allowing states to operate Medicaid through a
block grant for any eligibility group.
6. Presumptive Eligibility. In addition to repealing the Medicaid
expansion, Graham-Cassidy prevents states from using ``presumptive
eligibility'' and express lane eligibility after January 1, 2020. This
includes repealing the ability of states to permit their hospitals to
use presumptive eligibility for pregnant women, children, individuals
with breast and cervical cancer, and for family planning services and
supplies to obtain immediate Medicaid coverage when they end up in
emergency rooms or hospitalized for treatment without insurance means
they will end up with medical debt. We oppose repealing presumptive
eligibility.
7. Retroactive Eligibility. Medicaid currently provides coverage
up to three months before the month an individual applies for coverage.
This ``retroactive coverage'' protects individuals from medical
expenses they incurred before they apply for Medicaid. An individual
may not be able to apply for Medicaid immediately due to
hospitalization, a disability, or other circumstances. Retroactive
coverage provides that critical coverage and ensures providers are
reimbursed for their costs and that low-income individuals do not end
up facing severe medical debt or bankruptcy due to these medical
expenses. Graham-Cassidy reduces retroactive coverage for most Medicaid
beneficiaries to 2 months starting October 1, 2017. It requires states
to maintain 3 months of retroactive coverage only for seniors and
people with disabilities. We oppose reducing retroactive eligibility.
8. Essential Health Benefits (EHBs) for Medicaid Expansion
Beneficiaries. Under the ACA, states that expanded coverage to non-
pregnant childless adults had to provide coverage in at least the 10
``essential health benefit'' categories. Graham-Cassidy repeals this
requirement, effective December 31, 2019, resulting in beneficiaries
losing services such as mental health and substance use disorder
services and some no cost preventive health services. We oppose
repealing EHBs for Medicaid expansion enrollees.
9. Provider Taxes. Graham-Cassidy reduces states' ability to use
provider taxes to help pay the state's share of Medicaid. Cutting or
eliminating provider taxes is a substantial cost shift to states and
threatens access to care for millions of Medicaid enrollees. It also
undermines state flexibility to administer the Medicaid program without
doing anything to achieve programmatic efficiencies or improve quality.
We oppose reductions to provider taxes.
Women's Health
For Shyronn, a woman living with HIV in Georgia, having Medicaid allows
her to be active in her community. With Medicaid, she does not worry
about dying prematurely. Because of the services she receives through
Medicaid, she can live a normal life expectancy, remain a productive
citizen, and be there for her three children, including a 19-year-old
son who is actively serving our country in the United States Marine
Corps, a 14-year-old son who is engaged in school and community service
projects, and her 4-year-old daughter who is a ray of life who
brightens every soul she encounters. Medicaid has allowed her entire
family to stay healthy even when money is tight. Shyronn is passionate
about HIV prevention and empowering people living with HIV. She
volunteers her time to educate her community, youth, and policymakers
both in person and online about HIV risk, prevention and care. She is
also a member of Positive Women's Network-USA, a national membership
body of women that works to empower women living with HIV and develop
their leadership skills. Shyronn relies on essential supportive
services covered by Medicaid, such as mental health and case
management, in order to contribute to her family and community. She
says, ``the mental health counseling and case management I receive
through Medicaid work hand-in-hand to strengthen and support my ability
to handle the ups and downs of life. Having Medicaid has motivated me
to adhere to my medical appointments and treatment plans. When I did
not have Medicaid, I rarely sought medical attention.''
1. Planned Parenthood. The Graham-Cassidy bill resurrects the
previous ACA repeal bills' provisions targeting Planned Parenthood by
prohibiting the organization from participating in the Medicaid program
for one year, starting on the date of the bill's enactment. This would
mean many Medicaid enrollees would no longer be able to receive
Medicaid-covered services from their trusted provider of choice.
Excluding Planned Parenthood from the Medicaid program reduces access
to essential preventive care, such as contraception, tests and
treatment for sexually transmitted infections, and breast and cervical
cancer screenings. Other safety-net providers such as community health
centers lack the capacity to serve all the Medicaid enrollees who could
no longer receive care at Planned Parenthood. As a result, in some
areas of the country, particularly rural areas, people would lose
access to critical reproductive health services. We oppose excluding
Planned Parenthood from the Medicaid program.
2. Private Coverage. Nearly 7 million women and girls selected a
private insurance marketplace plan during the 2016 open enrollment
period.\3\ The majority relied on the ACA's federal subsidies to help
make the coverage more affordable. Graham-Cassidy eliminates the ACA's
current income-based premium tax credits and cost-sharing reductions
effective January 1, 2020. The bill then proposes to replace both
Medicaid expansion and marketplace subsidies with a time-limited block
grant that is set at 17% less than current funding, and which would
phase out completely after 2026.\4\ Taken together, these changes would
raise premiums, increase deductibles, and make it harder for women and
girls to afford high-quality comprehensive health care that meets their
needs. We oppose repealing the ACA's provisions governing marketplaces,
tax credits and cost-sharing assistance.
---------------------------------------------------------------------------
\3\ U.S. Department of Health and Human Services, Office of the
Assistant Secretary for Planning and Evaluation, ``Health Insurance
Marketplaces 2016 Open Enrollment Period: Final Enrollment Report''
(March 2016), https://aspe.hhs.gov/system/files/pdf/187866/
Finalenrollment
2016.pdf.
\4\ Center on Budget and Policy Priorities, ``Like Other ACA Repeal
Bills, Cassidy-Graham Plan Would Add Millions to Uninsured, Destabilize
Individual Market'' (September 2017), https://www.cbpp.org/research/
health/like-other-aca-repeal-bills-cassidy-graham-plan-would-add-
millions-to-uninsured.
3. Abortion Care in Private Plans. The Graham-Cassidy bill
includes restrictions that prohibit individuals and small employers,
effective January 1, 2018, from using federal tax credits to purchase
private health insurance plans that include abortion coverage beyond
the Hyde exceptions.\5\ The bill also specifically prohibits
individuals from using their Health Savings Accounts to pay for a High
Deductible Health Plan that covers abortion beyond the Hyde exceptions,
also effective January 1, 2018. These provisions could cause insurance
companies to stop offering plans that include abortion coverage
altogether, thereby putting abortion access further out of reach for
women in the private market. The provisions are also of particular
concern for states that broadly require abortion coverage in all or
most of their private plans, such as California and New York. The
restriction either forces these states to change their policies on
abortion coverage, or run the risk of dramatically reducing the number
of state residents who are eligible for federal tax credits. We oppose
restrictions on purchasing plans that cover abortion.
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\5\ The Hyde exceptions are abortions that are necessary to save
the life of the mother, or to terminate pregnancies that are the result
of rape or incest.
Rachel, who lives in Illinois, was overjoyed, but also overwhelmed when
she found out that she was pregnant. Though her pregnancy was planned,
Rachel did not have maternity coverage though her part-time job. She
intended to find a way to scrape together money and pay for her
prenatal care out of pocket. Rachel knew she wanted to give birth at
home, so she started to do research about what was available in her
hometown. Rachel met with a midwife shortly after she confirmed her
pregnancy. The midwife told Rachel that she was probably eligible to
get Medicaid to help her with the cost of prenatal care and labor and
delivery. The midwife advised Rachel on how to apply, and explained to
her exactly what she needed to do and bring to the Medicaid office in
order to apply. Rachel was found eligible for pregnancy-based Medicaid,
which she used throughout her pregnancy. She was able to use Medicaid
for all the care she needed during her pregnancy including labs, dental
care, ultrasounds, and screening tests. Her pregnancy was healthy and
uneventful, and she gave birth to her son Owen at home surrounded by
her family and friends, just as she wanted. After giving birth, Rachel
was able to get all of her postpartum care through Medicaid too,
including getting an IUD put in to avoid getting pregnant again before
she was ready. Rachel struggled with breastfeeding, but with Medicaid
she was able to see a lactation consultant and get a breast pump; she
was also connected to a breastfeeding support resource group. In
addition, her newborn son was immediately enrolled into Medicaid and
was able to get the well visits, screenings, and immunizations he
needed in his first year of life. After giving birth, Rachel was still
working part-time and trying make ends meet. Rachel says that her
ability to stay on Medicaid while she was adjusting to having a newborn
was ``so important!'' She adds, ``Medicaid is what allowed me to get
the care I needed as new mom and to take care of my baby.''
People With Disabilities
Julie, who lives in Colorado, was diagnosed with Multiple Sclerosis in
the late 1980s at age 20. Over the next several years, she had more
than a dozen hospitalizations with no way to pay for them, even though
she was working. After almost dying from being uninsured and
uninsurable, she was able to get coverage through Medicaid Home and
Community Based Services (HCBS). In more than 20 years on Medicaid
HCBS, she has not been in a hospital at all. To get on Medicaid, Julie
had to stop working for pay and go on Social Security Disability. In
late 2012, Colorado created a Medicaid Buy-In for Working Adults with
Disabilities. As a result, she was able to start working for pay, with
her salary ranging from $10,000 to $50,000 over the past few years. She
was able to give up Social Security Disability and now receives only
Medicaid and happily pays a premium. Medicaid provides her personal
care, including a high quality wheelchair for both indoors and outdoors
which is not available through Medicare or most insurance companies.
She also requires more than $1,000 a month of medications and supplies.
Because she can work, she is able to give back to the community
personally and through her job as the director of a nonprofit
organization, the Colorado Cross-Disability Coalition. Without
Medicaid, Julie fears she would be unable to function enough to work
and certainly cost the system more via inability to meet needs causing
illnesses that require hospital visits that she cannot afford. She says
that making changes to Medicaid, such as block granting would be
devastating. Julie says, ``Those of us with disabilities are always
blamed for costing the most in the system--but prevention with us costs
more. Instead of a $30 vaccination preventing $1,000 ER visit for the
flu, it might be a $15,000 wheelchair with complex rehab seating
systems preventing $1 million in pressure sores. People with
disabilities are the canaries in the coal mines of health care.''
1. Home and Community Based Services. As Graham-Cassidy would
impose deep cuts to Medicaid, states will have to make difficult
choices in their budgets between absorbing costs, cutting non-health
related state services (such as education) or cutting Medicaid. Some of
the services most at risk for cuts are Medicaid-funded Home and
Community Based Services (HCBS), including personal care services,
employment supports, residential supports, and specialized therapies.
HCBS are cost-efficient when compared to institutional care, but HCBS
are optional for states to provide while institutional care, like
nursing facilities, is often mandatory. Severe federal Medicaid cuts
put HCBS services directly in the crosshairs of state budget cuts. We
oppose per capita caps in Medicaid that will lead to cuts in HCBS.
2. Waitlists. Many HCBS services are delivered via Medicaid
waivers. Waivers let states limit the number of people getting services
and set special income limits to provide eligibility above regular
Medicaid eligibility limits. Unlike regular Medicaid, states can set up
a ``waitlist'' for some waivers. Thus, individuals who meet the waiver
program requirements may still have to wait for services until one of a
limited number of slots becomes available. In fact, over half a million
individuals are already on these waiting lists. Graham-Cassidy would
cut Medicaid by hundreds of billions, likely leading to even longer
waitlists as states struggle to provide required services to eligible
individuals before providing optional waiver services. We oppose per
capita caps in Medicaid that will lead to increase in waiting lists.
3. Home and Community-Based Attendant Supports. Graham-Cassidy
takes direct aim at the ``Community First Choice Option'' (CFC), which
provides states enhanced federal funding for home and community-based
services and supports under State Medicaid Plans. CFC services assist
individuals with Activities of Daily Living (ADLs) and habilitative
services. Graham-Cassidy repeals the 6% enhanced funding to cover these
services, which CBO predicts will reduce federal supports to
participating states by $19 billion. Instead,
Graham-Cassidy proposes $8 billion in demonstration funds, lasting just
4 years and limited to 15 states, with a preference for more rural
states. A limited, short-term demonstration program is no substitute
for the CFC option. We oppose cuts to the Community First Choice
funding.
4. Institutional Care. Medicaid traditionally does not fund
services in large (more than 16 beds) psychiatric facilities for adults
under age 65, such as state long-term hospitals, but it does fund
community-based rehabilitation services. In this way, Medicaid's
structure encourages states to limit the use of large, congregate
facilities--the trend has been to develop smaller, more community-based
facilities instead. Graham-Cassidy could reverse this trend--first by
offering funding to states for medium-length stays in these
institutions (30 days or less in a 6 month period), and then mandating
that states accepting this funding maintain the same number of licensed
beds at psychiatric hospitals owned, operated or contracted by the
state. By forcing states to maintain a specific number of ``beds,''
whether or not the demand exists, this provision creates an incentive
for states to fill such beds, even if people can be served in less
restrictive, more integrated environments. Not only does this raise
Medicaid concerns, but it also creates conflict with the state and
provider obligations under Olmstead to ensure people receive services
in the most integrated setting appropriate to their needs. We oppose
provisions that incentivize institutional care.
5. Pathways to Coverage for Children With Disabilities. Nearly all
states disregard parental income for children with significant
disabilities living at home to provide them Medicaid coverage. This
option, called the ``Katie Beckett program,'' saves parents from the
unbearable dilemma of having to place their child in institutional
care, where parental income is automatically disregarded, so their
child can qualify for Medicaid. The Katie Beckett program allows these
children to get the care they need while living at home. However, these
children tend to have expensive health needs and the coverage is
optional for states. Graham-Cassidy gives states an incentive to reduce
Medicaid enrollment and costs. In response, states may severely curtail
or eliminate their Katie Beckett programs. We oppose per capita caps
that could lead states to curb their Katie Beckett programs.
6. Parents and Home Care Workers. Juggling doctors' appointments,
therapies, and school meetings may mean parents of children with
disabilities cannot work full time. Medicaid expansion helps low-income
parents by making health care available to them, so they can keep
themselves healthy and take care of their children. Similarly, the home
care workers that actually provide HCBS for individuals with
disabilities often rely on Medicaid for their own care. One-in-three
home care workers live in households that qualify for Medicaid
expansion. Medicaid expansion indirectly supports individuals with
disabilities by making health care available to their parents and the
workers who provide HCBS. Converting Medicaid expansion into a block
grant and competing with other state health care funding needs will
likely result in decreased coverage for these parents and home care
workers. We oppose repeal of Medicaid expansion.
Other Provisions
1. Pre-Existing Conditions. Prior to passage of the ACA, insurers
regularly charged women higher premiums, or outright denied them
coverage, based on pre-existing condition exclusions such as being
cancer survivors, having had a cesarean section, having received
medical treatment from domestic violence or sexual assault, or for
being pregnant.\6\ The ACA changed this by prohibiting health plans
from either denying coverage or charging higher premiums to people with
pre-existing conditions. In addition to the issues specifically related
to maternity and newborn care above, health plans in states that choose
to modify or eliminate EHBs would likely offer less comprehensive plans
that lack the specific services people with pre-existing conditions
need. People with pre-existing conditions would be forced to pay higher
premiums for more comprehensive coverage that includes their needed
services. The result would be an end run around the ACA's prohibition
on discriminating against people with pre-existing conditions.
Elimination of this ACA protection could prevent women with chronic and
other pre-existing conditions from obtaining health insurance that
meets their needs, or indeed from obtaining health insurance at all.
This also effectively excludes individuals with disabilities from
plans, as many disabilities are, by definition, pre-existing
conditions. We oppose provisions weakening protections for individuals
with pre-existing conditions.
---------------------------------------------------------------------------
\6\ Id.
2. Essential Health Benefits (EHBs). Currently, insurers in the
small group and individual market must provide coverage in at least 10
``essential health benefit'' categories. Graham-Cassidy allows states
to waive this requirement. This has direct implications for people with
disabilities and for women's health. If a state waives EHBs such that
mental health benefits are excluded altogether from plans, mental
health parity protections are rendered meaningless because mental
health parity only applies if plans offer mental health benefits.
Similarly, insurers could choose not to provide habilitative services.
Even if plans include mental health or habilitative services, the
prohibition on lifetime and annual limits only applies to EHBs. If
states waive EHB requirements, any insurers that still cover these
important services could impose lifetime and annual limits.
Habilitation services are likely to be necessary in the long term for
families with children with I/DD. EHBs also includes maternity and
newborn care, as well as other services essential to basic reproductive
health such as preventive and wellness services, mental health and
substance use disorder services, and prescription drugs. One study
found that if a state eliminated the EHB requirement to cover maternity
care, the premium for a maternity care rider would cost a woman an
additional $17,320 in 2026.\7\ Prior to passage of the ACA, only 12% of
individual health plans across the country covered maternity care,
resulting in high out-of-pocket costs for pregnant women.\8\
Elimination of the EHB requirement would again leave many women without
adequate maternity care or force them to incur debt to obtain care. It
would also effectively allow plans to practice gender discrimination by
requiring women to pay more for plans that do include maternity care.
We oppose waivers of EHB requirements.
---------------------------------------------------------------------------
\7\ Sam Berger and Emily Gee, Center for American Progress,
``Senate Health Care Bill Could Drive Up Coverage Costs for Maternity
Care and Mental Health and Substance Use Disorder Treatment'' (June
2017), https://www.americanprogress.org/issues/healthcare/news/2017/06/
20/434670/senate-health-care-bill-drive-coverage-costs-maternity-care-
mental-health-substance-use-disorder-treatment.
\8\ National Women's Law Center, ``Women and the Health Care Law in
the United States'' (May 2013), https://nwlc.org/wp-content/uploads/
2015/08/us_healthstateprofiles.pdf.
If you have any questions about this statement, please contact Mara
Youdelman, Managing Attorney of the National Health Law Program's DC
---------------------------------------------------------------------------
office, (202) 289-7661,[email protected].
______
National Multiple Sclerosis Society
1100 New York Avenue, NW, Suite 440-E
Washington, DC 20005
tel +1 202-408-1500
fax +1 202-408-0696
https://www.nationalmssociety.org/
Statement of Bari Talente, Executive Vice President, Advocacy
The National Multiple Sclerosis Society has urged all members of
Congress to work towards bipartisan solutions to strengthen access to
comprehensive and more affordable health coverage and care so people
living with Multiple Sclerosis (MS) can live their best lives. The
proposal put forth by Senators Graham, Cassidy, Heller and Johnson
(Graham-Cassidy) is neither bipartisan nor a solution, and we urge all
to oppose it. The voices of people living with the disease must not be
left out of the decisions that determine their ability to secure the
care they need and deserve.
Graham-Cassidy would repeal current protections for people with pre-
existing and high-cost conditions like MS. It would end Medicaid
expansion coverage and federal subsidies for health insurance, leaving
over 23 million currently insured people in jeopardy of losing their
access to health care altogether.\1\
---------------------------------------------------------------------------
\1\ Manatt Health, ``State Policy and Budget Impacts of New Graham-
Cassidy Repeal and Replace Proposal,'' September 2017.
As a Texan living with Multiple Sclerosis, the Graham-Cassidy
bill keeps me awake with worry each night. . . . It took
$170,000 to keep me, the vegan triathlete who happens to have
an incurable neurodegenerative disease, healthy and able-bodied
---------------------------------------------------------------------------
for one year.
--Jennifer Kiser, Roanoke, TX
The proposal would give states wide latitude to waive current insurance
benefit requirements and other standards of fairness for people with
pre-existing conditions. People with MS in states that waive these
protections could face substantially higher premiums or find themselves
in plans without coverage for the medications, rehabilitation benefits,
MRIs or other services that help them remain healthy, productive and
independent.
Any legislation, such as Graham-Cassidy, that will allow states
to set their own rules and offer low-quality insurance
policies, will have life and death consequences for millions of
people across the country, and could be financially devastating
for people with MS like me and families that have had a loved
one fall ill.
--Bob Finkelstein, Philadelphia, PA
If enacted, Graham-Cassidy would dramatically cut and redistribute
federal funds to states, with some states seeing reductions of up to
50% or more in support of care for low-income individuals.\2\ People
living with MS know the current system is far from perfect, but are
fearful of measures that would erode improvements in access to quality
MS care they have witnessed in recent years.
---------------------------------------------------------------------------
\2\ Ibid.
When diagnosed with Multiple Sclerosis in 1999, I became a
medical hostage. Since this was pre-Affordable Care Act, my
same insurance company could refuse coverage, slot me into a
high-risk pool, or keep me from receiving the ``too new''
disease stalling medications debuting at that time, which have
since become the standard of care. It's not okay to gamble with
our health. I don't want to return to the days when we lacked
protections and access. Please don't gamble with our health.
---------------------------------------------------------------------------
Reject Graham-Cassidy.
--Vivian Leal, Reno, NV
In addition to the dangerous policies contained in Graham-Cassidy, the
Society is dismayed that only one hearing is being held on the
proposal, and by the absence of regular order. Legislation that impacts
one sixth of the U.S. economy and the well-being of millions requires
thoughtful consideration and debate. It is also reckless to vote on
such significant legislation without a comprehensive score from the
Congressional Budget Office that provides data on its impact on
premiums and coverage. The Society implores Congress to reject Graham-
Cassidy and return to bipartisan work that will improve access to
affordable, quality health coverage and care for people with MS.
______
National Partnership for Women and Families
1875 Connecticut Avenue, NW, Suite 650
Washington, DC 20009
Statement Submitted by Debra L. Ness, President
Chairman Hatch and Ranking Member Wyden,
The National Partnership for Women and Families is a nonprofit,
nonpartisan organization that has fought for decades to strengthen our
health care system and advance the rights and well-being of women. On
behalf of women across the country who are the health care decision-
makers for themselves and their families, we write in strong opposition
to the Graham-Cassidy-Heller-Johnson proposal (``the Graham-Cassidy
proposal'') to repeal the Affordable Care Act. The Graham-Cassidy
proposal is yet another assault on the health care women and families
rely on.
The Graham-Cassidy proposal would devastate women's health care and
coverage. For example, it would:
Repeal the ACA marketplace financial assistance, endangering the
health and economic security of the 6.8 million women who depend on the
Marketplace for affordable health coverage.\1\
---------------------------------------------------------------------------
\1\ U.S. Department of Health and Human Services. (March 11, 2016).
``Issue Brief: Health Insurance Marketplaces 2016 Open Enrollment
Period: Final Enrollment Report.'' Retrieved September 22, 2017, from
https://aspe.hhs.gov/system/files/pdf/187866/Finalenrollment2016.pdf.
End Medicaid as we know it, harming the nearly 1 in 5 adult
women who are covered by Medicaid.\2\
---------------------------------------------------------------------------
\2\ National Partnership for Women and Families. (September 2017).
``Fact Sheet: Women's Health Coverage: Sources and Rates of
Insurance.'' Retrieved September 22, 2017, from http://
www.nationalpartnership.org/research-library/health-care/womens-health-
coverage-sources-and-rates-of-insurance.pdf.
Block Medicaid enrollees from accessing care at Planned
Parenthood, denying millions of people access to essential preventive
---------------------------------------------------------------------------
services such as birth control and cancer screenings.
Eliminate guaranteed coverage of critical health services for
women, like maternity care, prescription drug coverage and mental
health services.
Allow insurance companies to discriminate against people with
pre-existing conditions, including 67 million women and girls.\3\ This
means coverage could become prohibitively expensive for those in dire
need of care. For example, insurers would charge about $17,320 more in
premiums for pregnancy.\4\
---------------------------------------------------------------------------
\3\ U.S. Department of Health and Human Services. (January 5,
2017). ``Issue Brief: Health Insurance Coverage for Americans with Pre-
Existing Conditions: The Impact of the Affordable Care Act.'' Retrieved
September 22, 2017, from https://aspe.hhs.gov/system/files/pdf/255396/
Pre-ExistingConditions.pdf.
\4\ Berger, S., and Gee, Emily. Center for American Progress.
(September 18, 2017). ``Graham-Cassidy ACA Repeal Bill Would Cause Huge
Premium Increases for People With Pre-Existing Conditions.'' Retrieved
September 22, 2017, from https://www.americanprogress.org/issues/
healthcare/news/2017/09/18/439091/graham-cassidy-aca-repeal-bill-cause-
huge-premium-increases-people-pre-existing-conditions/.
Discourage private insurance coverage of abortion by penalizing
health plans that offer it with burdensome bureaucratic requirements,
and pushing abortion coverage further out of reach for many women.
Denying coverage for abortion means women must cover the costs of care
themselves--often delaying care to come up with the funds, or
---------------------------------------------------------------------------
sacrificing other essential expenses to do so.
Lead to 32 million people losing coverage;\5\ $4 trillion in
cuts to states over the next 2 decades;\6\ and a 20 percent increase in
premiums for the same coverage.\7\
---------------------------------------------------------------------------
\5\ Collins, Sara R. (September 20, 2017). ``What Are the Potential
Effects of the Graham-
Cassidy ACA Repeal-and-Replace Bill? Past Estimates Provide Some
Clues.'' Commonwealth Fund. Retrieved September 22, 2017, from http://
www.commonwealthfund.org/publications/blog/2017/sep/potential-effects-
of-graham-cassidy.
\6\ Carpenter, E., and Sloan C. Avalere. (September 20, 2017).
``Graham-Cassidy-Heller-Johnson Bill Would Reduce Federal Funding to
States by $275 Billion'' [press release]. Retrieved September 22, 2017,
from http://avalere.com/expertise/life-sciences/insights/graham-
cassidy-hell
er-johnson-bill-would-reduce-federal-funding-to-sta.
\7\ Congressional Budget Office. (December 8, 2016). ``Repeal the
Individual Health Insurance Mandate.'' Retrieved September 22, 2017,
from https://www.cbo.gov/budget-options/2016/52232.
Put simply: this proposal would devastate the health and economic
---------------------------------------------------------------------------
security of women and families.
It is long past time for Congress to work in a bipartisan way to
stabilize the insurance markets and make quality, affordable care
available to all, not continue trying to repeal the Affordable Care
Act, which has been the greatest advance for women's health in a
generation.
If you have any questions, please reach out to Katie Martin, vice
president for health policy and programs, at
[email protected] or 202-986-2600.
______
National Women's Law Center
Statement of Gretchen Borchelt,
Vice President for Reproductive Rights and Health
The National Women's Law Center (``Center'') has worked for 45 years to
advance and protect equality and opportunity for women and girls in
every aspect of their lives, including health care and economic
security. The National Women's Law Center submits this statement in
strong opposition to the Graham-Cassidy-Heller-
Johnson (``Graham-Cassidy'') proposal to repeal the Affordable Care Act
(ACA).
If passed, the Graham-Cassidy proposal would threaten women's health,
take away women's access to health services and coverage, and
jeopardize the economic security of women and families. By gutting
federal support, ending the Medicaid program as we know it, permitting
insurance practices that discriminate against women, imposing
restrictions that effectively eliminate abortion coverage, and barring
Medicaid funding to Planned Parenthood health centers, the Graham-
Cassidy proposal would undo progress women have made since the ACA was
passed, and leave women without access to the affordable and quality
health care and coverage that they need.
The Graham-Cassidy Proposal Would Gut Federal Funding for Health Care,
Leaving Women Without Critical Coverage
The Graham-Cassidy proposal would fundamentally change federal
financing of health coverage. It would eliminate federal funding for
the ACA's tax credits and cost sharing reductions and the Medicaid
expansion starting in 2020, and replace it with a smaller block grant
to the states that would disappear in 2026. This block grant would be
inadequate, with states receiving less money than they would under the
ACA and, according to the Center for Budget Policy Priorities, would
``cause many millions of people to lose coverage.'' \1\ This radical
restructuring would be especially devastating to women.
---------------------------------------------------------------------------
\1\ Jacob Leibenluft, et al., ``Like Other ACA Repeal Proposals,
Cassidy-Graham Plan Would Add Millions to Uninsured, Destabilize
Individual Market'' (September 20, 2017), available at https://
www.cbpp.org/research/health/like-other-aca-repeal-proposals-cassidy-
graham-plan-would-add-millions-to-uninsured.
Due to the restructuring, women would lose health insurance coverage
that they have recently gained thanks to the ACA. According to the most
recent Census data, the Center calculates that more than 89.4 million
women have health insurance, with an additional 7.2 million women
gaining health insurance from 2013-2016. This coverage contains
protections that, among other things, ensure women are not charged more
than men for the same coverage, are not treated as a pre-existing
condition, and have coverage for essential and preventive health care
needs, like maternity care, birth control, and well-woman visits. The
Graham-Cassidy proposal would take this important coverage away from
---------------------------------------------------------------------------
women.
By eliminating the ACA's tax credits and cost sharing reductions, the
Graham-
Cassidy proposal would also put affordable health coverage out of reach
for the millions of women who rely on federal financial assistance to
afford coverage. According to the Center's calculations, as of 2014,
over 9 million women who would otherwise have gone without affordable
health insurance were eligible to benefit from the ACA's tax credits,
including a high number of women of color. Separately, the cost sharing
reductions help to reduce copayments, deductibles, and other out-of-
pocket costs for marketplace enrollees. More than 5.6 million people,
or almost 60 percent of ACA marketplace enrollees, received cost
sharing reductions in 2016, and on average, cost sharing reductions
help to reduce individuals' out-of-pocket costs by roughly $1,100 per
person.\2\ These reductions are significant for women who, according to
data both pre- and post-ACA, are more likely to forego health care
because of costs, including increased out-of-pocket costs. Eliminating
the federal assistance to purchase health insurance, as the Graham-
Cassidy proposal does, would only compound existing barriers to
purchasing health coverage for women, who are more likely to live in
poverty than men, earn less than men, and are more likely to work in
low-wage jobs with less ability to absorb extra costs. These cost
barriers are particularly prohibitive for women of color who are more
likely to live in poverty than whites and who were more likely to be
uninsured pre-ACA due to costs.
---------------------------------------------------------------------------
\2\ Sarah Lueck, Center on Budget and Policy Priorities,
Interactive map: ``Cost-Sharing Subsidies at Risk Under House GOP
Health Proposal'' (March 21, 2017), available at https://www.cbpp.org/
blog/interactive-map-cost-sharing-subsidies-at-risk-under-house-gop-
health-proposal.
Elimination of the Medicaid expansion would be especially devastating
for women. According to the Center's calculations, states expanding
Medicaid have seen the largest increases in Medicaid enrollment of
women ages 18-64 between 2013-2015. Medicaid expansion has been
particularly important for low-income, childless women who were not
eligible for Medicaid before expansion. Without coverage, low-income
women are more likely to go without health care because of cost, are
less likely to have a regular source of care, and utilize preventive
---------------------------------------------------------------------------
services at lower rates than low-income women with health insurance.
The Graham-Cassidy Proposal Would End Medicaid as We Know It, Posing
Particular Harm to Women Struggling to Make Ends Meet
In addition to ending funding for the Medicaid expansion, the Graham-
Cassidy proposal makes radical changes to the Medicaid program, which
would end the program as we know it and pose particular harm to women
who are already struggling to make ends meet.
The Graham-Cassidy proposal would dismantle the Medicaid program by
converting Medicaid's current federal-state partnership, which
automatically responds to changing needs, into a per capita cap system.
It would allow states to convert their Medicaid programs into either a
block grant or per capita cap system. Block grant and per capita cap
systems limit and cut federal funding and shift to states the risk of
increases in Medicaid costs. Either one would force states to cut
Medicaid coverage and benefits--and possibly other services as well.\3\
For example, block granting Medicaid could give states the ability to
reduce the number of people covered by Medicaid by eliminating
eligibility for some people now entitled to benefits under law (for
example, pregnant women with family incomes below 133% of poverty);
denying or delaying services to eligible people by establishing
enrollment caps and wait lists; and creating administrative barriers to
enrolling and maintaining enrollment. A Medicaid block grant could
allow states to reduce Medicaid benefits by eliminating some services
that are currently required (for example, family planning services and
diagnostic and treatment services for young children); setting limits
on the utilization of benefits; and raising the amount that low-income
families must pay for such services through premiums, deductibles, and
co-payments.
---------------------------------------------------------------------------
\3\ For a more detailed analysis of how per capita caps and block
grants harm women; see National Women's Law Center, ``The Stealth
Attack on Women's Health: What Caps on Medicaid Funding Would Mean for
Women'' (April 2017), available at https://nwlc.org/wp-content/uploads/
2017/04/Medicaid-Per-Capita-Caps.pdf. See also National Women's Law
Center, ``The Stealth Attack on Women's Health: The Harmful Effects
Block Granting Safety Net Programs Would Have on Women'' (April 2017),
available at https://nwlc.org/wp-content/uploads/2017/04/Medicaid-
Block-Grants.pdf.
This would be devastating to women, who disproportionately make up the
Medicaid population. The Center calculates that in 2016, over 17.4
million women had Medicaid coverage, with over 4.4 million gaining
coverage between 2013-2016. These women are now receiving coverage for
critical maternity care, family planning services, and long-term care,
among other benefits.\4\ And this coverage is helping to make women
more economically secure, by keeping women and their families from
medical debt and bankruptcy, providing coverage not linked to
employment so that women can seek positions that offer higher wages or
better opportunities, and covering birth control, which allows women to
determine whether and when to start a family, expanding their
educational and career opportunities. Medicaid payments to providers
also directly support women's jobs.\5\ With its radical changes that
would throw women off Medicaid coverage and change the program, the
Graham-Cassidy proposal threatens the health and economic security of
low-income women and families across the country.
---------------------------------------------------------------------------
\4\ Although Medicaid covers a range of services women need, it is
important to note that federal law restricts federal Medicaid coverage
of abortion except if the pregnancy is the result of rape or incest, or
if the woman's life is in danger.
\5\ National Women's Law Center, ``Medicaid Is Vital for Women's
Jobs in Every Community'' (June 2017), available at https://nwlc.org/
wp-content/uploads/2017/06/Medicaid-Jobs-Re
port.pdf.
Moreover, the Graham-Cassidy proposal allows states to condition
Medicaid coverage upon punitive work requirements. A work requirement
is unprecedented in Medicaid; it goes against the objective of the
Medicaid program, which is to provide health coverage to low-income
people who cannot otherwise, afford it, which helps them attain or
retain the capacity for independence and self-care. A work requirement
contravenes these objectives by jeopardizing the vital coverage that
provides enrollees with the care they need to obtain or maintain
employment. Women are especially likely to lose health care coverage
under a Medicaid work requirement, because they are more likely than
men to face particular barriers to employment such as being the sole
caregiver of children or aging parents.\6\ Work requirements are
particularly indefensible given that they have proven not to work when
applied to other programs, and because they are based on the false
narrative that Medicaid enrollees do not work and are taking advantage
of the program's benefits, which belies reality and is predicated on
over-invoked racialized stereotypes of enrollees that ignore the lived
experiences of all low-income people across racial lines.
---------------------------------------------------------------------------
\6\ For a more detailed analysis of how work requirements imposed
on Medicaid enrollees would harm women, see National Women's Law
Center, ``The Stealth Attack on Women's Health: Medicaid Work
Requirements Would Reduce Access to Care for Women Without Increasing
Employment'' (May 2017), available at https://nwlc.org/resources/the-
stealth-attack-on-womens-health-medicaid-work-requirements-would-
reduce-access-to-care-for-women-without-increasing-employment/.
The Graham-Cassidy Proposal Would Allow Plans to Reinstate Practices
---------------------------------------------------------------------------
That Discriminated Against Women
The latest version of the Graham-Cassidy proposal would allow states to
modify rules for plans funded through the block grants created by the
proposal. This could include changing the requirement that plans
provide coverage of the ACA's 10 essential health benefits, which
include coverage that women need like prescription drug coverage,
mental health care, and maternity and newborn care. This would allow
plans to once again refuse to offer the critical benefits that women
need. For example, as the Center documented, prior to the ACA, only 12
percent of the most popular plans on the private insurance market
offered maternity coverage.\7\ Lack of coverage for maternity care left
women shouldering costs ranging from over $30,000 for vaginal births to
over $50,000 for caesarian births.\8\ These high costs can be
impossible for women to pay out-of-pocket and may result in women
foregoing needed prenatal care and suffering compromised health
outcomes, including maternal and infant mortality, which is already
alarming high among black women.
---------------------------------------------------------------------------
\7\ National Women's Law Center, ``Turning to Fairness: Insurance
Discrimination Against Women Today and the Affordable Care Act'' (March
2012), available at https://www.nwlc.org/sites/default/files/pdfs/
nwlc_2012_turningtofairness_report.pdf.
\8\ Truven Health Analytics, ``The Cost of Having a Baby in the
United States'' (January 2013), available at http://
transform.childbirthconnection.org/wp-content/uploads/2013/01/Cost-of-
Having-a-Baby1.pdf.
In addition, the latest version of the Graham-Cassidy proposal would
allow states to modify the rules for coverage of women's preventive
services. This historic provision of the ACA requires plans to provide
women--without cost-sharing--coverage for an evidence-based set of
women's preventive services, including birth control, breastfeeding
supports and supplies, and well-woman visits.\9\ In passing this
provision, Congress intended to remedy gaps in preventive services
requirements, and recognized that the failure to cover women's
preventive health services meant that women paid more in out-of-pocket
costs than men for basic and necessary preventive care and in some
instances were unable to obtain this care at all because of cost
barriers. According to the Center's calculations, over 62.4 million
women now have this coverage, which has been critical to women's health
and economic security. For example, no-cost coverage of birth control
has enabled women to access the birth control method that is most
appropriate for them when they need it without cost being an
obstacle.\10\ It has also furthered women's economic security; one
study found that the provision helped women to save $1.4 billion in one
year on the birth control pill alone.\11\ Allowing states to get rid of
this requirement, as the Graham-Cassidy proposal would do, will send
women back to a day when cost-sharing and lack of coverage determined
whether they had the care they need, with long-term effects on the
health and economic security of women, children, and families across
the country.
---------------------------------------------------------------------------
\9\ The list of women's preventive services was reaffirmed as
recently as December 2016 by a panel of experts convened by the
American College of Obstetricians and Gynecologists, as part of the
Women's Preventive Services Initiative. ``Women's Preventive Services
Initiative, Recommendations for Preventive Services for Women: Final
Report to the U.S. Department of Health and Human Services,'' Health
Resources and Services Administration (HRSA), Washington, DC: American
College of Obstetricians and Gynecologists (December 2016).
\10\ For more information showing how the birth control benefit is
working, see National Women's Law Center, ``The Affordable Care Act's
Birth Control Benefit: Too Important to Lose'' (May 2017), available at
https://nwlc.org/resources/the-affordable-care-acts-birth-control-
benefit-too-important-to-lose/.
\11\ Nora V. Becker and Daniel Polsky, ``Women Saw Large Decrease
in Out-of-Pocket Spending for Contraceptives After ACA Mandate Removed
Cost Sharing,'' 34 Health Affairs 1204 (July 2015), available at http:/
/content.healthaffairs.org/content/34117/1204.abstract.
The proposal also threatens the health and economic security of the
estimated 65 million women with pre-existing conditions by allowing
states to set their own rules, including allowing health insurance
issuers to charge higher premiums based on health status. This means
that although health insurance coverage may be theoretically available
to a woman with a pre-existing condition, the insurance company could
price the premium in such a way that she is effectively denied
coverage. Prior to the ACA, the Center published extensive research
documenting insurance practices of charging women more for coverage
because of ``pre-existing conditions'' unique to them, such as
undergoing a Cesarean delivery.\12\ The Graham-Cassidy proposal would
allow insurance companies to reinstate this discriminatory practice. No
woman should again be charged more because she has had a prior
pregnancy or Cesarean delivery, because she received fertility
treatment, had breast or cervical cancer, is a survivor of domestic
violence, or because she had medical treatment following a sexual
assault.
---------------------------------------------------------------------------
\12\ National Women's Law Center, ``Still Nowhere to Turn:
Insurance Companies Treat Women Like a Pre-Existing Condition'' (2009),
available at https://nwlc.org/wp-content/uploads/2015/08/
stillnowheretoturn.pdf.
The Graham-Cassidy Proposal Effectively Bans Plans From Offering
---------------------------------------------------------------------------
Comprehensive Coverage That Includes Abortion
The Graham-Cassidy proposal contains a host of abortion restrictions.
During the time that the Graham-Cassidy proposal allows the ACA tax
credits to exist, the proposal denies tax credits to individuals who
choose comprehensive plans that cover abortion and denies the small
business tax credit to those businesses that offer comprehensive plans
that include abortion. The proposal also prohibits individuals from
using money in personal health savings accounts for abortion and bans
states from using the newly created block grants to fund plans that
cover abortion. These provisions have no other purpose than to ban
private insurance companies from covering abortion. Eliminating access
to abortion coverage would deny women meaningful access to basic health
care and endanger women's health. Provisions like these that deny
insurance coverage of abortion exacerbate the economic instability of
women and their families and actually increase the risk that women and
their families will be forced into a cycle of poverty. When women are
forced to pay for abortion care, studies show many divert funds from
necessities like food, electricity, or rent in order to pay for the
costs of an abortion. For those women unable to get the care they need,
they are more likely to be living in poverty a year later than women
who are able to obtain an abortion.\13\
---------------------------------------------------------------------------
\13\ For more information on the harm of insurance coverage bans on
women, see National Women's Law Center, ``State Laws Regulating
Insurance Coverage of Abortion Have Serious Consequences for Women's
Equality, Health, and Economic Stability'' (August 2017), available at
https://nwlc.org/wp-content/uploads/2017/08/50-State-Insurance-
Coverage-of-Abortion-1.pdf.
The Graham-Cassidy Proposal Would Force Medicaid Patients to Give Up a
---------------------------------------------------------------------------
Trusted Provider of Critical Preventive Services
The Graham-Cassidy proposal bars Medicaid patients from going to
Planned Parenthood health centers for care, including cancer
screenings, birth control, and treatment for sexually transmitted
infections. For decades, Planned Parenthood has been an essential
health care provider for women with Medicaid, and more than half of
Planned Parenthood patients rely on Medicaid for health coverage.\14\
Planned Parenthood health centers are a trusted source of critical
family planning services for individuals in a way unmatched by other
providers. Taking away patients' ability to access the critical care
Planned Parenthood provides would have consequences for women's health,
economic security, and lives.\15\ The non-partisan Congressional Budget
Office (CBO) estimates that if Planned Parenthood is denied federal
Medicaid funding, an estimated 390,000 people will completely lose
access to preventive health care and 650,000 will face reduced access
to preventive care,\16\ and ``the number of births in the Medicaid
program would increase by several thousand'' in one year due to reduced
access to birth control.\17\
---------------------------------------------------------------------------
\14\ Planned Parenthood Action Fund, ``Medicaid and Reproductive
Health'' (last visited May 17, 2017), https://
www.plannedparenthoodaction.org/issues/health-care-equity/medicaid-and-
reproductive-health.
\15\ For a more detailed look at what it would mean to individuals
to lose the ACA and Planned Parenthood, see National Women's Law
Center, ``Double the Trouble: Health Care Access Without the Affordable
Care Act or Planned Parenthood'' (2017), available at https://nwlc.org/
wp-content/uploads/2017/06/final_nwlc_DoubleTrouble2017.pdf.
\16\ Congressional Budget Office, ``Cost Estimate: H.R. 3134 Defund
Planned Parenthood Act of 2015'' (September 16, 2015) at 3, available
at https://www.cbo.gov/sites/default/files/114th-congress-2015-2016/
costestimate/hr3134.pdf.
\17\ Congressional Budget Office, ``Cost Estimate: American Health
Care Act'' (March 13, 2017) at 23, available at https://www.cbo.gov/
system/files/115th-congress-2017-2018/costestimate/
americanhealthcareact.pdf.
* * * * * * *
The Affordable Care Act has changed the landscape for women's health,
enabling women to obtain affordable health care and coverage that
better meets their needs. The Graham-Cassidy proposal would upend that
progress, taking insurance coverage away from women, allowing insurance
companies to once again discriminate against women, and jeopardizing
women's health, lives, and economic security. Like every other ACA
repeal effort that has been introduced and considered in this Congress,
the Graham-Cassidy proposal would be devastating to women and families
across this country. It is time to stop playing politics with women's
health. The Center urges senators voting on this proposal to oppose it.
______
Oklahoma Council of the Blind (OCB)
P.O. Box 1476
Oklahoma City, OK 73101
Phone: 405-740-6227
U.S. Senate
Committee on Finance
Dirksen Senate Office Bldg.
Washington, DC 20510-6200
Statement Submitted by Vicky Lynn Golightly, President
The Oklahoma Council of the Blind (OCB) is a statewide organization of
approximately 400 blind and visually impaired Oklahomans and their
family members. Virtually all of our members, who span all ages, have
pre-existing medical conditions. They use a variety of health
insurance.
Following are our major priorities for any health care and health
insurance reform measures that may be considered by Congress.
Preserve these critical protections provided by the Affordable Care Act
(ACA):
The prohibition against denial of coverage for pre-existing
conditions;
The guaranteed renewability of coverage;
The prohibition against individual underwriting;
The requirement that essential health benefits be part of every
qualified health plan;
The prohibition against lifetime monetary caps;
The prohibition against discrimination in health programs; and
The extension of mental health parity to the individual and
small group market.
Above all, we urge that any new health care system ensure that
Americans will not be charged higher premiums, copays, and deductibles,
or be subjected to coverage exclusions or limitations, based on
disability, age, or pre-existing medical condition.
We oppose giving states the option to waive patient protections now in
place, because in our view, this type of option will ultimately lead to
unavailable, unaffordable, and/or substandard health coverage for
blind, disabled, and elderly citizens.
Medicaid is an essential provider of health services for Americans who
are aged, blind, or disabled. For children and youth with disabilities,
health and related services received through Medicaid lay the
foundation for healthier adult life that makes employment possible. For
youth and adults with the most severe developmental and intellectual
disabilities, Medicaid's home-and-community-based waiver options are
essential to prevent even more costly nursing home care and to enable
these individuals to achieve their potentials, whether through work or
daily life. The home and-community long term care waivers for elderly
and disabled under Medicaid currently enable many Oklahomans to stay
living at home, retaining as much independence as possible, and
avoiding the higher cost of nursing home care. Because Medicaid today
offers states several ways to advance health, maximize personal
independence, and improve quality of life--all while preventing
excessive institutionalization and higher long-term care expenditures,
we strongly urge Congress to maintain these effective features of the
Medicaid program and provide the funding needed to sustain them.
The Council recognizes that challenges inherent in crafting a health
care system that meets the goals of quality coverage for all Americans
at affordable prices, while reining in the constant growth of health
care costs. We only hope that in trying to find ways to address those
challenges, Congress will commit to preserving the ACA patient
protections that allow blind and disabled Americans to obtain and
afford health coverage. Many of us remember a time when these
protections were not in place, leaving disabled individuals without
needed medical care, forcing more to seek public benefits, while
driving families into bankruptcy. A return to those days would be very
costly for the nation, both in terms of people and prosperity.
Thanks to the Committee for holding this public hearing on health care
reform. We appreciate the chance to offer comments for the hearing
record.
Regards,
Vicky Lynn Golightly
President
______
Letter Submitted by Lecia Papadopoulos
September 24, 2017
U.S. Senate
Committee on Finance
Dirksen Senate Office Bldg.
Washington, DC 20510-6200
I am writing this letter in two capacities as a citizen:
1. As the mother and guardian of a disabled young woman who likely
would not be alive today without the benefits from the Home and
Community Based Services (HCBS) funded by Medicaid and the State of
Colorado.
While my daughter is a lovely young woman, her needs are
significant medically and in regard to mental health, as well as
cognitively, requiring constant oversight and supervision. Without the
present-day HCBS supports through Medicaid, she would not have access
to the extensive medical and mental health care she needs, and I would
have to choose between working and providing sufficient supervision to
ensure her safety.
2. As a former small business owner who contributed jobs, tax
revenue and opportunity in Colorado for nearly 20 years, with up to six
contractors in various locations nationally, Fortune 500 clients, and
consistently six figures in annual revenue.
Ultimately, I chose to close that business for reasons that
included the increasing cost and challenges to obtaining sufficient
supports for my daughter's medical, mental health, developmental, and
cognitive needs.
In these capacities, I am compelled to bring to this committee's
attention several stark and fiscally imprudent shortcomings about the
Graham-Cassidy proposal.
The proposal to shift to a block grant per capita Medicaid funding
model and eliminate key provisions of the Affordable Care Act will not
produce the stated intended results and will in fact contribute to
worsening the current healthcare access and affordability crisis.
Specifically it:
1. Will not stabilize the individual health insurance market and
reduce premiums--Numerous citations document the expected turmoil and
cost increases that American citizens can expect as a result of this
proposal including:
2. As many as half of the nation's population needing maternity
care, mental health and substance abuse benefits, rehabilitative and
habilitative services, and pediatric dental benefits would likely face
increases in their out-of-pocket costs. Some people would have
increases of thousands of dollars in a year.
3. Residents with pre-existing conditions in states housing one-
sixth of the nation's population ``would be unable to purchase
comprehensive coverage with premiums close to those under current law
and might not be able to purchase coverage at all'' [emphasis added].
Prior estimates of less-draconian healthcare proposals by
the CBO expect a likely 20% increase in premium prices in 2018 as a
result of similar legislation.
4. Will not reduce healthcare costs--According to the Kaiser
Family Foundation.org, reducing federal Medicaid spending by using
block grant reductions and slow-growing per capita limits slows the
federal government's spending on healthcare by setting grant amounts
and caps below expected spending levels. It does not slow the spending
in healthcare overall, nor does it address the growing need of
vulnerable populations for healthcare services or the fluctuating needs
related to economic downturns, natural disasters, etc. All such
variables and shortfalls are left to the states to determine whom and
what to cut.
5. Will not increase states' flexibility--as reported in the
FamiliesUSA.org's Medicaid Fact Sheet, states already have ``a lot of
flexibility in their Medicaid programs,'' including flexibility to
define:
i. What services are covered.
ii. How providers are paid for servicers.
iii. How services are delivered.
iv. Eligibility levels.
Limiting federal dollars for Medicaid, according to the Kaiser
Family Foundation.org, would create a system that is ``less responsive
to state decisions and changing program needs,'' in effect reducing
flexibility. The proposal also allows states to use the block grants
for different programs than states may currently be supporting,
creating greater uncertainty.
6. Will not improve efficiencies in healthcare delivery to
citizens--Again, according to the Kaiser Family Foundation.org, ``most
Medicaid programs have few options for easy ways to trim spending. Many
efficiencies were adopted by states during the last two major
recessions when revenues dropped and budgets were constrained. Medicaid
already grows at slower rates compared to private health insurance
premiums. Most states currently operate programs with low
administrative costs and provider reimbursement levels below other
payers.''
7. Will not increase access to care--According to the Center on
Budget and Policy Priorities, if the Graham-Cassidy proposal is
adopted, ``millions of people with pre-existing conditions would lose
access to these protections, and, as a result, would lose access to
needed coverage and care.'' The Center on Budget and Policy Priorities
further reports that ``The Congressional Budget Office (CBO) has
previously estimated that the repeal-without-replace approach would
ultimately leave 32 million more people uninsured. Cassidy-Graham would
presumably result in even deeper coverage losses than that in the
second decade as the cuts due to the Medicaid per capita cap continue
to deepen.''
8. Will not protect people with pre-existing conditions--According
to the Center on Budget and Policy Priorities, a ``provision of the
block grant funding states would receive under the plan would let them
obtain waivers of ACA pre-existing conditions protections and benefit
standards for any insurance plan subsidized by block grant funding. For
example, a state that used a small portion of its block grant funding
to provide even tiny subsidies to all individual market plans could
then waive these protections for its entire individual market.
Likewise, states that used block grant funding to offer or subsidize
coverage for low-income people could offer plans with large gaps in
benefits. States seeking waivers would have to explain how they
`intend' to maintain access to coverage for people with pre-existing
conditions, but they wouldn't have to prove that their waivers would
actually do so.''
9. Will not ensure that states' plans provide equitable and
meaningful coverage--According to the Center on Budget and Policy
Priorities, prior to enactment of the ACA:
i. 75% of individual markets excluded maternity coverage.
ii. 45% excluded substance abuse treatment.
iii. 38% excluded mental health care.
As to the likelihood of whether states will take advantage of
these waivers of exclusion, the Center on Budget and Policy Priorities
reports that the Graham-Cassidy proposal is similar to the waiver
authority included in so-called ``MacArthur amendment'' waivers that
were included in the House-passed ACA repeal proposal. Analyzing those
waivers, the Congressional Budget Office (CBO) concluded:
i. States accounting for one-sixth of the nation's population
would choose to let insurers charge higher premiums based on health
status. In those states, ``less healthy individuals (including those
with preexisting or newly acquired medical conditions) would be unable
to purchase comprehensive coverage with premiums close to those under
current law and might not be able to purchase coverage at all''
[emphasis added].
ii. States accounting for half of the nation's population
would choose to let insurers exclude essential health benefits. In
those states, ``services or benefits likely to be excluded . . .
include maternity care, mental health and substance abuse benefits,
rehabilitative and habilitative services, and pediatric dental
benefits.'' People needing these services ``would face increases in
their out-of-pocket costs. Some people would have increases of
thousands of dollars in a year.''
10. Will contribute to increased healthcare costs overall--
According to the Centers for Disease Control and Prevention, preventive
services, studies have shown that:
Cost-sharing strategies such as deductibles, co-insurance
and co-payments reduce the likelihood that preventive services such as
mammograms will be used. The Graham-Cassidy proposal will increase cost
sharing by removing access to health insurance for many people and
dramatically increasing out-of-pocket costs, as reported by the Center
on Budget and Policy Priorities.
Also reported by the Center on Budget and Policy Priorities,
the use of preventive services can prevent and greatly reduce the costs
related to chronic diseases such as diabetes, heart disease and cancer,
which together are responsible for 7 out of 10 deaths of Americans each
year and 75% of the nation's healthcare spending. Financial barriers
deter many Americans, even those with insurance, from obtaining
preventive health services. Building these services into the standard
costs of care is advantageous to everyone.
11. Will have negative economic impacts that affect everyone--The
National Immigration Law Center reports that access to health
insurance:
Reduces both health and non-health related debt. . . .
Uninsured individuals who become hospitalized experience a host of
financial setbacks over the next four years, including reduced access
to credit and a significantly higher likelihood of filing for
bankruptcy.
Enables consumers to spend more in local economies . . .
individuals and families [have] more disposable income to spend on
goods and services. In addition to increasing tax revenues, this
additional spending produces a ``multiplier effect,'' as increased
business revenues are passed on to suppliers and employees, who use
them in turn. One estimate puts the multiplier effect of Medicaid
expansion at between 1.5 and 2 times the amount of new federal Medicaid
spending.\6\
Increases workplace productivity and economic output. . . .
People without insurance are often in poor health due to deferred
treatment and uncontrolled chronic conditions. Poor health results in
multiple dimensions of lost productivity: adults whose health status
prevents them from working, workers who miss time from their jobs
because of health problems, and workers who are working but less
productive because of their health conditions. One study found that
workers who were uninsured missed almost five more days of work each
year than those who had insurance. This assessment while illuminating,
leaves out the reduced productivity and economic impact on families
with one or more members who chronically and seriously ill.
The Centers for Disease Control report that ``[h]ealth
problems are a major drain on the economy, resulting in 69 million
workers reporting missed days due to illness each year, and reducing
economic output by $260 billion per year. Increasing the use of proven
preventive services can encourage greater workplace productivity.''
To close, I want to forcefully request that the Graham-Cassidy-Heller-
Johnson proposal be shelved and not brought forward for debate or vote.
All efforts to address our nation's healthcare challenges must take
place in public to bring in bipartisan ideas and concerns, as well as
to explore and make use of expert perspectives from people who have
dedicated their lives to improving public health, and above all to be
focused on dealing with the real issues:
Containment of overall healthcare costs, not just federal,
state, or individual spending.
Control over individual, state, and federal cost outlays through
innovative knowledge sharing, skill development, and cost-saving
programs that improve patient outcomes.
Increased use of technologies and structures that improve the
use of preventive medicine, counseling, cross-disciplinary teams, and
other proven techniques.
Access to affordable and meaningful care that includes common
needs at no additional surcharge, such as preventive services, mental
health and behavioral services, services for substance abuse, pediatric
and adult dental services, vision services, rehabilitative and
habilitative services, women's health and pregnancy services, services
for the elderly, and no lifetime caps or pre-existing condition
exclusions.
Greater simplicity in accessing consistent types and qualities
of services regardless of geographic location, employer, and income
level.
Elimination of for-profit health insurance and healthcare
services providers.
Etc.
Thank you kindly for the opportunity to contribute to this important
national discussion that so profoundly affects my family and literally
every American.
Best regards,
Lecia Papadopoulos
Enclosed: the attached pages briefly summarize my experience as the
mother of a daughter with numerous complex and serious medical,
developmental, cognitive, and mental health conditions.
______
Highlights from my experiences with the American healthcare system
before and after the ACA, including Medicaid Home and Community Based
Services (HCBS) in Colorado, as mother to a daughter born with
significant needs
For several years before my daughter was born, back in 1997, I had to
pay extra to have an insurance policy that would cover pregnancy costs.
When I learned that she had cystic fibrosis, the most common life-
shortening inherited condition among Caucasians in the U.S., I tried
not to think about what I would do once her lifetime cap was reached.
My daughter can never be without group medical insurance. Imagine my
despair, as a fully employed mom of a seriously ill infant, when I
learned that I could not relocate near my family because none of the
four states near them offered group insurance options for self-employed
people at any price. Nor could I take a staff job as I needed
flexibility to work odd hours to be able to manage my daughter's many
doctor appointments and hospitalizations to keep her alive.
Due to the many interventions, including tube feedings and
hospitalizations she required as an infant and toddler, my daughter
didn't learn to eat by mouth until she was nearly through grade school.
In the late 90s, ``supplemental'' nutrition was not a covered benefit,
even though she could eat no food other than what would go through the
tube; we battled insurance for an exception.
When children don't learn to eat at the right time, they may never
learn to eat or, if they do, they may never really enjoy it. This
window is relatively small. Fortunately for my daughter, she was
waitlisted ``only'' 6 to 8 months for the Colorado Children's HCBS
Medicaid waiver before she was enrolled and gained access to the
specialized therapies my expensive health insurance wouldn't cover. It
took years to teach her to eat; rehabilitative benefits are designed
for stroke patients who are re-acquiring a skill they've already
learned. My daughter had to acquire a new skill, which takes much
longer to address.
The Medicaid wavier removed the risk of bankruptcy for our family. I
could get support for Lily's care during parts of the day so that I
could still work. The bulk of her medical bills were always paid, and I
could keep up with the co-payments. Some equipment and medicines would
not have been available without Medicaid, namely a vest for her
respiratory treatments, which she needs 2-4 times daily, and enzymes
needed with every meal and snack so her body can obtain nutrition from
her food. The enzymes can be thousands of dollars monthly, with co-pays
in the hundreds of dollars, and that is only one required medication
out of roughly two dozen.
Medicaid gave her access to the medications, equipment and physicians
she needed, first for keeping her alive despite cystic fibrosis, and
then to address developmental and behavioral deficits related to a
hereditary genetic anomaly called Trisomy X, Autism and mental health
conditions. In short, the Medicaid HCBS waivers in Colorado, funded by
a mix of federal and state dollars, saved her life and allowed her to
grow up, in a home, with a gainfully employed parent. Today, the adult
waivers allow her to remain in the community, to continue to learn and
work on gaining job skills and to keep her health in a good status
despite the progressive and debilitative nature of cystic fibrosis.
______
The Partnership for Medicaid
600 13th Street, NW, Suite 500
Washington, DC 20005
www.partnershipformedicaid.org
The Partnership for Medicaid--a nonpartisan, nationwide coalition of
organizations representing health care providers, safety net health
plans, counties and labor--is opposed to the Graham-Cassidy-Heller-
Johnson proposal to restructure the Medicaid program into a block grant
or per capita cap model. We call on the Senate to protect Medicaid and
to reject continued efforts that will roll back coverage for the 70
million people that depend on this vital program.
The Partnership is dedicated to preserving and improving the Medicaid
program, so that it better meets the needs of the beneficiaries it
serves. Medicaid delivers necessary health care services and other
related supports to our nation's most vulnerable children, pregnant
women, parents, individuals with disabilities, seniors, and other
adults. Any legislation that makes fundamental changes to the Medicaid
program must not undermine the quality of services or access to care
for the populations that this safety net program has served for 52
years.
We strongly oppose continued efforts in the Senate to explore
devastating cuts to the Medicaid program. The Graham-Cassidy-Heller-
Johnson proposal maintains near identical Medicaid provisions to those
in the failed Better Care Reconciliation Act that would impose funding
caps that threaten the viability of the Medicaid program. Medicaid
beneficiaries rely on Congress to preserve the program and to make
improvements that promote access and quality.
Cuts to Medicaid for budget gains are unacceptable and undermine the
long-term stability of the program. The policies in this proposal are
designed to meet fiscal objectives. They do not strengthen the Medicaid
program, nor do they guarantee access to care. We remain in opposition
to efforts that simply shift the cost burden onto local and state
governments, health care providers and individual beneficiaries.
The Partnership strongly urges the Senate to protect Medicaid and
reject efforts to dismantle the program as called for in the Graham-
Cassidy-Heller-Johnson proposal.
While this statement represents the collective views of the Partnership
as a coalition, it has not been officially endorsed by each individual
Partnership member organization.
AFL-CIO American Academy of Family
Physicians
American Academy of Pediatrics American Congress of Obstetricians
and Gynecologists
American Dental Association American Dental Education
Association
American Health Care Association America's Essential Hospitals
Association for Community
Affiliated Plans Association of Clinicians for the
Underserved
Catholic Health Association of the
United States Children's Hospital Association
Easterseals The Jewish Federations of North
America
Medicaid Health Plans of America National Association of Community
Health Centers
National Association of Counties National Association of Pediatric
Nurse Practitioners
National Association of Rural
Health Clinics National Council for Behavioral
Health
National Health Care for the
Homeless Council National Hispanic Medical
Association
National Rural Health Association
______
Prevent Blindness
211 West Wacker Drive, Suite 1700
Chicago, Illinois 60606
toll free 800-331-2020
local 312-363-6001
fax 312-363-6052
https://www.preventblindness.org/
The Honorable Orrin Hatch The Honorable Ron Wyden
Chairman Ranking Member
Committee on Finance Committee on Finance
U.S. Senate U.S. Senate
Washington, DC 20510 Washington, DC 20510
Dear Chairman Hatch and Ranking Member Wyden:
Prevent Blindness is the nation's leading nonprofit, voluntary
organization committed to preventing blindness and preserving sight.
Prevent Blindness represents millions of people of all ages across the
country who live with low vision and vision-related eye diseases. We
appreciate the opportunity to submit a Statement for the Record in
response to the Senate Finance Committee's September 25th hearing to
consider the Graham-Cassidy-Heller-Johnson proposal.
After reviewing the Graham-Cassidy-Heller-Johnson amendment to H.R.
1628, the American Healthcare Act (ARCA) as introduced by U.S. Senators
Lindsay Graham, Bill Cassidy, Dean Heller, and Ron Johnson (deemed
``Graham-Cassidy''), we have very serious concerns with the precedent
that this legislation establishes for patients seeking vision and eye
healthcare services. Understanding that the Congressional Budget Office
(CBO) has not released a complete economic impact statement and score
for this proposal, we are nonetheless troubled by consistent estimates
of significant loss of healthcare coverage for millions of Americans
starting in just over 2 years not just for those who rely on Medicaid
but for the uncertainty these proposals would create in the health
insurance market for individuals purchasing non-group policies. We
outline our additional concerns below.
Impacts of a Block Grant Medicaid Program
Prevent Blindness is deeply concerned with projections that Medicaid
spending will be reduced by $1 trillion over the coming decade. The
proposals set forth to convert federal funding into a block grant
program will force states to cut eligibility for vulnerable patients.
In some states, Medicaid is often the only source of vision and eye
care for many adults and children. Facing an uncertain and underfunded
future of the Medicaid program, states will likely have no choice but
to cut vision screenings and eye health services that can potentially
curb the progression of and, in some cases, prevent altogether
incidents of vision loss for children, aging Americans; and patients
with chronic diseases.
Protections for Patients With Pre-Existing Conditions
We have serious reservations that the legislation does not go far
enough to ensure, without question, that patients with a pre-existing
condition will be able to acquire affordable insurance plans. Under
such financial constraints, patients will not be empowered to
prioritize their vision and eye health and will likely forgo cost-
effective, sight-saving preventive care.
Essential Health Benefits
As written, we believe this bill will have a particularly detrimental
impact on people with chronic conditions, such as diabetes, as the
legislation would significantly weaken EHBs for both adults and
children.
Chronic Disease Management: Eye disorders rank 5th among the top
8 chronic conditions in the United States, with the overall cost of
vision problems calculated at $145 billion annually. Eye health
problems have a strong correlation to many chronic health conditions
such as smoking, depression, and falls. Diabetes, one of the most
common chronic diseases among adults, can lead to vision loss through
diabetic retinopathy, diabetic macular edema, cataracts, and glaucoma.
Children's Vision and Eye Exams: Vision impairments and eye
disorders are the 3rd leading chronic condition among children with
costs for direct medical care; vision aids and devices; and caregivers
amounting to $10 billion per year. Our nation's families are already
shouldering 45% of these costs. Common childhood eye disorders and
vision impairments are easily treatable if caught early; however, as
written, the Graham-Cassidy legislation jeopardizes early detection and
cost-effective treatments that could prevent lifelong vision impairment
or permanent loss of vision.
We know that prevention works. Ensuring that Americans of all ages have
access to the most basic and preventive services will only contribute
to healthy development in young children, successful school
performance, and the long-term health of our nation.
Proposal to Implement a ``Per Capita Cap'' Medicaid Formula
The proposal to tie federal funding to a state program's enrollment
places an untenable burden on states to maintain enrollment using their
own resources. As the difference between federal funding and the cost
of Medicaid programs increase, states will have no choice but to decide
between increasing their contributions or cutting them by restricting
access and benefits, including services for vision and eye health, or
cutting off enrollment altogether. Both options place vulnerable
patients in a situation in which their access to care is severed as a
result of ineligibility or a lack of available services.
Prevent Blindness strongly urges the Senate to reconsider many of the
problematic provisions of the Graham-Cassidy legislation that would
jeopardize cost-effective, preventive interventions to avoidable vision
loss. We stand ready to assist the Committee as needed, and urge you to
work in a bipartisan manner to confront our nation's healthcare
challenges. If you should have any questions, please reach out to Sara
D. Brown, Director of Government Affairs at (312) 363-6031 or sbrown@
preventblindness.org.
Sincerely,
Hugh R. Parry
President and Chief Executive Officer
______
Letter Submitted by Brenda Prochnow
September 22, 2017
U.S. Senate
Committee on Finance
Dirksen Senate Office Bldg.
Washington, DC 20510-6200
Members of the Senate Committee on Finance,
I am writing you today as the parent of a daughter who is medically
fragile and has major medical and developmental disabilities. As you
may know, Medicaid funding provides individuals with disabilities the
opportunity to receive community based, non-institutional supports in
order that they can continue to live at home with their families or
move into supported living arrangements within the community. Without
these supports, these individuals could be forced into nursing homes
and other more expensive living options. This program is funded through
a mix of federal and state funds. It is a lifeline for families with
children and adults with disabilities who need ongoing supports for
health and safety as well as improved quality of life. The Graham-
Cassidy-Heller-Johnson bill will negatively impact our daughter and all
the population of people with disabilities and put them at risk.
My daughter, Tara, is 30 years old and is able to live in our loving
home with us because of the Medicaid program Family Care. Without this
funding, she would be forced into a nursing home and not have a good
quality of life. She is G-tube fed 24 hours a day on a feeding pump,
has a tracheostomy and ventilator dependent. She is cognitively
impaired and non-verbal. Believe it or not, she is happy and currently
has a good quality of life! She has in home nursing care that provides
total care for her. With the current proposed Medicaid cuts and caps it
leaves us extremely worried about the quality of care she may receive
or worse yet, she may not be able to live with us in our loving
environment, due to cheaper alternatives. The cuts will also affect the
livelihood of nurses who provide care to people with disabilities in
the homecare setting.
I am writing on behalf of my family and many other individuals who are
receiving or waiting to receive services through Medicaid funding.
These services provide basic, stable supports that would enable each of
us; disabled individuals and caregivers alike, to more adequately
support ourselves and our families, while contributing more fully to
our communities.
I hope you, as legislators, are remaining informed to adequately fund
essential Medicaid services and that you support funding for these
services. The system is becoming less and less stable as providers and
families struggle with the long term impact of ongoing funding cuts. A
stable support system for families and service providers significantly
improves the quality of life for people with developmental disabilities
like our daughter, Tara, while increasing each person's opportunities
to become much more productive members of our society. I urge you to
vote ``no'' on the Graham-Cassidy-Heller-Johnson bill and instead ask
the Senate to continue its work through the bipartisan market
stabilization efforts.
Sincerely yours,
Brenda Prochnow
______
Resource Center for Accessible Living, Inc. (RCAL)
727 Ulster Avenue
Kingston, NY 12401
TTY (845) 331-4527
FAX (845) 331-2076
Main (845) 331-0541
Statement of Alex Thompson, Systems Advocate
The Resource Center for Accessible Living (RCAL) is an independent
living center in the upper Hudson Valley of New York. RCAL strongly
opposes the Graham-
Cassidy amendment (S. Amdt. 1030) to the American Health Care Act of
2017 (H.R. 1628) heretofore known as ``the bill.'' RCAL serves people
with disabilities in Ulster County, New York. People with disabilities
in our area are currently struggling with numerous barriers to
accessible housing, employment, adequate healthcare, and community
living. The Graham-Cassidy bill, should it become law, would cause
significant harm to people with disabilities by exacerbating barriers
to adequate healthcare.
The bill proposes per capita caps on the money spent to provide care
for Medicaid recipient populations. It also proposes the elimination of
the adult Medicaid expansion created by the Affordable Care Act, which
has been utilized by people with disabilities, their families, and
caregivers. The per capita caps are essentially cuts due to a
underlying financing scheme which is based is wishful thinking rather
than fulfilling essential needs, and would severely limit the
availability of home- and community-based services. These types of
services are vital because they allow people to live and work in the
community as opposed to an institutional setting where freedom of
choice is limited. People we serve at RCAL depend on some form of home-
and community-based services. Medicaid is a necessity for many and
should not be cut with frivolous disregard for the many people with
disabilities, seniors, and others that depend on its services as a
safety net program.
It is important that you understand that home- and community-based
services are rarely available through private insurance plans or are
too restrictive to account for someone's actual needs. The
Congressional Commission on Long Term Care of 2013 made known in its
published report the deficiencies in the private marketplace for long
term care coverage and the necessity of Medicaid as a major provider of
Long Term Supports and Services. For example, a person living with
paralysis, may need personal care services to help with the activities
of daily living - such as dressing, bathing, using the bathroom, and
eating. A private insurance plan may only cover an hour of assistance
per day, which would be wholly inadequate to cover these activities,
let alone other important activities like getting to and from work or
class, visiting the grocery store, etc.
Medicaid helps people with disabilities get an education and prepare to
work by providing funds for access and care in school. Medicaid helps
people with disabilities work by funding medical equipment and services
that gives us independence. Without the right kind of care, a person
would not be able to learn, work and live independently, but could be
stuck in a nursing home. The economy actually suffers when people with
disabilities are trapped in beds instead of being able to live the life
they want in their community.
States, like New York, help ensure people with disabilities can live in
the community by implementing the Community First Choice program. The
Affordable Care Act increased the amount the federal government would
match State spending on related services. The Graham-Cassidy bill
ignores the value of the program and would eliminate federal funding
(approximately $19 billion) for all state community first choice
programs. The bill tries to make up for this massive blow to
independent living by giving a (temporary) 4 year ``demonstration'' of
$8 billion to assist States wanting to continue offering ways for
people to live independently in the community Currently, only eight
States have Community First Choice plans in the post Affordable Care
Act environment. Therefore, it should be obvious that the temporary
demonstration is not adequate bridge a gap in service while also
eliminating a program that has proven to increase the well-being of
people with disabilities.
We support and encourage bipartisan efforts to improve the health and
well-being of people with disabilities; the bill before you is not
that.
______
Letter Submitted by Eva Shiffrin
To: U.S. Senate Finance Committee
Re: Testimony submitted for consideration to the hearing to consider
the Graham-Cassidy-Heller-Johnson proposal on September 25, 2017
Dear Senate Finance Committee Members,
I write to express my opposition to the Graham-Cassidy-Heller-Johnson
Proposal (the Proposal). The Proposal includes draconian, cruel and
amoral substantive provisions, stripping health care from tens of
millions of vulnerable Americans while purporting to fix health care
and make it available and affordable to all Americans. It was also
developed in a deeply shameful, undemocratic process that flies against
the desires of 88% of Americans.
The Proposal's cuts to traditional Medicaid are draconian. Millions of
elderly individuals and people with disabilities rely on traditional
Medicaid for their lives, their well-being, and their independence.
Although the Congressional Budget Office Analysis has not been
completed for this Proposal, it is similar or worse to previous bills
that would radically restructure Medicaid, kicking millions of
Americans off health care. Thousands of people will die as a result.
Previous and less draconian versions of this bill estimate that federal
support will drop by $750-$800 billion by 2026, with deeper cuts to
follow. I work with people with disabilities every day and know
firsthand how important and lifesaving Medicaid health care can be.
People with disabilities rely on critical Medicaid services like
tracheotomy care, nursing care, dialysis, cancer treatments,
occupational therapy, speech therapy, life-saving medications, durable
medical equipment, and more to work and live lives with dignity and
independence. These people are our family members, our neighbors, our
coworkers, and our friends. We are the wealthiest country in the world.
We can and should provide Medicaid for the elderly and people with
disabilities.
This Proposal will also impact pregnant women and children, who are
insured by Medicaid in high numbers. In Wisconsin, 28% of all kids are
covered by Medicaid. Nearly half of all U.S. births are covered by
Medicaid. For many children with disabilities and extensive health care
needs, Medicaid is lifesaving and cutting it could literally put
children's lives at risk. Children who receive regular health care to
treat things like asthma, diabetes, and treatable medical problems fare
better in school, miss fewer days of school, are more likely to
graduate, and earn higher wages than those without health care. We as a
country have always thought that the children are our future. This
Proposal takes us backwards. The potential impacts of this Proposal for
children and pregnant women are frankly deeply disturbing.
The changes to the Affordable Care Act are also deeply troubling. The
proposal opens up the door to imposing pre-existing condition
exclusions again, limiting essential health services, and reducing the
affordability of health insurance, which will result in millions more
losing health insurance they only recently gained. All of the studies
done thus far on health outcomes for individuals newly insured through
the ACA show the enormous positive impact of insured status. I
personally know many individuals with disabilities who relied on ACA
coverage when they could no longer work due to a diagnosis, but had to
wait 2 years after a disability determination before Medicare would
begin and who were not eligible for Medicaid. I also know multiple
friends who relied on the ACA to receive treatment for cancer. These
individuals could not work, but they also did not qualify for Social
Security. These friends owe their lives to the Affordable Care Act. I
also have friends with full time jobs that did not offer health
insurance and could only afford health insurance offered through the
ACA with subsidies. These individuals were able to obtain services to
treat chronic illnesses such as diabetes, illnesses that would worsen
without treatment and then require costly treatment, but are
preventable. The Proposal fails to make insurance more affordable and
in fact, will price ordinary Americans out of any insurance market,
returning to the days when a cancer patient who couldn't work but
couldn't access health care, where a person with asthma couldn't afford
health insurance due to a pre-existing condition, where a person
working a full-time job couldn't afford health insurance. This is not
what Americans want.
Many of the very sponsors of this Proposal vowed that they would
replace the ACA with something better and more affordable. This
Proposal fails miserably in all respects. It has also been crafted,
introduced, and discussed in a deeply undemocratic manner. The fact
that many Senators are unwilling to even wait to discuss the Proposal
and provide for full and fair hearings on it after it has been analyzed
by the Congressional Budget Office exposes this process as a deeply
shameful charade, one that ignores the desires of the vast majority of
the American people. The last bill scored by the CBO had an approval
rating of 12%, yet this bill is moving forward and is even worse than
the last bill scored.
I am submitting this testimony to the committee to ensure that it is
entered into the official record of these proceedings. If this bill
passes and goes into effect, I want the record of this committee to
show that those who voted for this Proposal were fully aware of its
devastating and destructive impact and were told by millions of
American citizens that this is not what we want.
Eva Shiffrin
______
Letter Submitted by Barbara Burke Sorensen
To: The United States Senate Committee on Finance, I submit these
comments for the hearing to consider the Graham-Cassidy-Heller-Johnson
Proposal, September 25, 2017.
My full name is Barbara Burke Sorensen. I submit these comments for the
hearing to consider the Graham-Cassidy-Heller-Johnson proposal,
September 25, 2017.
I write on behalf of my son Olaf A. Sorensen. Olaf is 35 years old and
has been disabled from birth. Olaf's initial diagnosis was autistic
disorder, with the added diagnoses over the years of generalized
anxiety, then PTSD (Post Traumatic Stress Disorder) and depression with
psychotic features.
Olaf was recommended for institutional placement at age 2 or 3. I have
worked in the ensuing 32-33 years with health care providers to keep
Olaf out of institutional placement. Because of the Katie Beckett
children's waiver, there was funding for physical therapy, occupational
therapy, and speech therapy, and Olaf was able to learn to walk, talk
and interact in the community--all things that it was predicted by
medical doctors Olaf would never achieve. With the funding available
under home and community Medicaid waivers, Olaf was able to remain in
his community since he qualified for a CIP IB waiver at age 11, at a
much lower cost than the institutional placement would have been, up to
the present, although the name has changed to IRIS waiver. Currently
the monthly cost for Olaf's IRIS waiver Medicaid supports (he requires
24/7 care and supervision) is approximately $14,000.00. The monthly
cost for the institutional placement would be $33-$34,000.00. And would
have been, over the many years I have labored day in and day out, to
make a place for Olaf in this world.
I cannot express clearly enough to the authors and co-sponsors of this
bill that their bill will condemn my son Olaf to institutional
placement because this bill decimates the level of funding that Olaf's
level of disability requires for him to stay where he is. As a former
member of the Wisconsin BPDD, I am aware of the many disabled adults
across this nation, for whom this bill is tantamount to a death
sentence.
That breaks my heart completely, as both a mom and as an American, to
know that our federal legislators would propose devastating cuts to
funding for disabled people. It is especially heart breaking coming
from legislators who assure us and the nation that they are pro-life.
The ``least among us'' require consistent funding and care. Miniscule
Medicaid funding that is left will not allow for that outcome. I hope
and pray that this government will declare its support for people with
disabilities even in times of economic stress.
Recorded history shows that in Germany, resentment of the economic
burden on society of disabled children led to their ultimate deaths
through ``mercy killings.'' I hope that our American society will not
take that slippery slope. Please, Senators, do not forsake the
disabled. America is better than that.
Sincerely, Barbara Burke Sorensen
______
Statewide Parent Advocacy Network (SPAN) and Family Voices-New Jersey
35 Halsey Street, 4th Floor
Newark, NJ 07102
(973) 642-8100 (973) 642-8080 Fax
Website: www.spannj.org
Email: [email protected]
http://www.familyvoices.org/states?id=0031
SPAN and Family Voices-New Jersey comments to the Senate Finance
Committee for the hearing on the Graham-Cassidy healthcare bill
Thank you for the opportunity to comment on the Graham-Cassidy
healthcare bill. Family Voices is a national network that works to
``keep families at the center of children's healthcare.'' The NJ State
Affiliate Organization for Family Voices is housed at the Statewide
Parent Advocacy Network (SPAN), NJ's federally designated Parent
Training and Information Center, Family-to-Family Health Information
Center, Parent to Parent USA affiliate, and chapter of the Federation
of Families for Children's Mental Health. The Family Voices Coordinator
also serves on the Board of the National Alliance on Mental Illness
(Mercer-NJ) and the Progressive Center for Independent Living. She is
also NJ's representative (volunteer) of the Caregiver Action Network,
representing caregivers across the lifespan.
While SPAN provides information, training, technical assistance, parent
to parent support, advocacy, and leadership development for all NJ
families of children ages birth to 26, our priority is on children at
greatest risk due to disability, special health care or emotional
needs, poverty, discrimination based on race, culture, language,
immigrant status, or economic status, or involvement in the child
welfare or juvenile justice systems. Thus, we are particularly
concerned with ensuring that the needs of children with special
healthcare needs and their families are adequately addressed in
federal, state and local policies and practices.
We understand that this hearing is to gather information on state
flexibility and fiscal burden. At SPAN, our priority is serving the
needs of children, youth, young adults and families, especially those
who face the greatest challenges. Thus, we value access to affordable,
high quality care over state flexibility and relief from fiscal burden.
We also note that we strongly believe that there should be consistency
nationally, particularly given mobility across states. The proposed
legislation will result in inequity of healthcare across states. We
remain concerned with annual/
lifetime caps and note that rescinding policies will increase medical
debt and bankruptcy, not improve our economy (according to Families,
USA 60% of bankruptcies are due to medical debt.) We are deeply
concerned that this bill is a total repeal without replacement.
Millions will lose coverage, Medicaid will be cut and transformed in
negative ways that will hurt low-income individuals, children and
families, including in particular those with disabilities and special
healthcare needs, and those with pre-existing conditions will be
harmed.
We are very concerned that if states (including but not limited to New
Jersey) lose Federal Medical Assistance Percentages (FMAP) for
Medicaid, they won't have same amount of funding to provide services at
their current levels, levels which are already inadequate to meet
children and families' needs.
We acknowledge your expressed concern with the individual mandate but
note that, without it, there will be adverse selection. The individual
mandate is critical to ensure that the health insurance marketplace
includes young and healthy as well as older individuals and those with
disabilities and special healthcare needs. This individual mandate is
similar to the requirement for individuals to ``purchase'' retirement
insurance via Social Security. Further, it is in the public interest to
require all Americans to have health insurance, as health insurance is
a cost-effective way to ensure that people have access to health care
when and if they become ill or develop a disability or special
healthcare need.
Regarding reduction of fiscal burden, we don't see the Graham-Cassidy
bill doing this for consumers as premiums will increase, plan values
decrease, and cost-
sharing increase. In addition, we do not think that insurers and health
companies should get tax breaks which are being offset by cuts to
Medicaid. Lastly, we are concerned that there will not be access to
coverage as people with pre-existing conditions, disabilities, or the
elderly will not be able to participate in the market due to pricing.
We acknowledge that the Department of Health and Human Services is
charged with providing essential human services such as Medicaid,
Medicare, and better access to private coverage. HHS responsibilities
include mental health treatment, services to older individuals, and
direct health services delivery. However, we remain deeply concerned as
current proposals to amend the Affordable Care Act (ACA) and Medicaid
demonstrate that Essential Health Benefits are no longer being seen as
necessary and the critical safety nets of Medicaid/Medicare are under
attack. Access to private coverage will be also affected by allowing
pre-existing condition exclusions, 6 month waiting periods, annual/
lifetime caps, and rescission of policies. Repealing the ACA has
nothing to do with the cuts being proposed to Medicaid, other than the
expansion population. According to the AAP (American Academy of
Pediatrics), 37 million children are covered under Medicaid. In
addition, there are over 60 million covered for mental health or
substance abuse per the APA (American Psychiatric Association), and
their data shows that the opioid epidemic is rising in every state.
There is nothing in the proposed legislation that will improve health
coverage or health care, and many components that will negatively
impact health coverage and health care and endanger the lives and
health of millions of Americans.
We understand that consideration is being given as to whether HHS rules
advance or impede priorities in the areas of stabilizing markets,
affordability, returning regulatory authority to states, streamlining/
flexibility, reducing burden, and identifying regulations that reduce
jobs. In the area of stabilization, adverse selection due to the
elimination of the individual mandate will destabilize the market. With
regard to affordability, people with pre-existing conditions or the
elderly will be priced out. And work provisions for Medicaid are
unnecessary as 75% of people on Medicaid work; the rest are children,
disabled, and the elderly. In relation to returning authority to
states, access to healthcare shouldn't be based on where you live;
state waivers will complicate issues and also affect service delivery
due to state budget deficits. In the area of streamlining and
flexibility, this terminology is being misused in order to provide
fewer services. Regarding reducing burden, instead of starting at the
beginning it seems more efficient to revise as needed what is already
in place under the ACA. In regard to job reduction, homecare for
elderly and direct support professionals for people with disabilities
will be impacted resulting in the loss of home care jobs (estimate
between 305,000 and 713,000 jobs lost) due to Medicaid per capita caps
per the Center for Consumer Engagement in Health Innovation. In
addition, this is in violation of the Supreme Court Olmstead decision
and returning more people to more costly institutional care rather than
providing home and community based services which is movement backward
not progress.
We acknowledge that HHS previously solicited comments on the ``Patient
Protection and Affordable Care Act; Market Stabilization,'' to affect
premiums, ``curb abuses, lower prices, and reduce adverse selection.''
We support lower premiums; however the CBO (Congressional Budget
Office) will not be able to complete a report in the timeframe.
Premiums will rise for all, especially for the elderly or disabled.
Regarding curbing abuses, the percentage of Medicaid fraud is extremely
low--and the majority of fraud is perpetuated by providers as opposed
to patients. It is unconscionable to cut this program as a trade-off
for tax cuts for the wealthy. Finally, for adverse selection, this will
actually be increasing due to the elimination of the individual
mandate. Further, high-risk pools for those with pre-existing
conditions will be unaffordable and states using this model have
already demonstrated that this tactic fails.
While HHS claims that it has initiated these steps to attempt to
address stabilizing the market, affordability, and affirming the
traditional authority of the States, the reality is that the market
will be de-stabilizing due to high risk pools and adverse selection. We
disagree that there will be choice if consumers can't afford health
care as all should have access and if consumers can't get affordable
coverage due to pre-existing conditions or lack of affordable options
that provide Essential Health Benefits. We also disagree that this will
address affordability as premiums are rising and others will be priced
out due to their condition or age. We are very concerned with state
options as this will allow annual/lifetime caps and rescission of
policies otherwise.
Please note that the largest major medical group (American Medical
Association), patient/provider groups (ALS Association, American Cancer
Society Cancer Action Network, American Diabetes Association, American
Heart Association, American Lung Association, Arthritis Foundation,
Cystic Fibrosis Foundation, Family Voices, JDRF, Lutheran Services in
America, March of Dimes, National Health Council, National Multiple
Sclerosis Society, National Organization for Rare Diseases, Volunteers
of America, WomenHeart), and even insurance groups (Blue Cross Blue
Shield plans and America's Health Insurance Plans) are opposing this
plan as it will negatively impact women, children, people with
disabilities, and the elderly resulting in a sicker, more costly,
American populace. Please consider our constructive comments above in
response to your request for information.
Sincerely,
Diana MTK Autin Lauren Agoratus, M.A., parent
Executive Co-Director, SPAN NJ Coordinator, Family Voices @
SPAN
Email: [email protected] Email: [email protected]
______
Letter Submitted by Shawn M. Steen
U.S. Senate
Committee on Finance
Dirksen Senate Office Bldg.
Washington, DC 20510-6200
September 21, 2017
Re: Hearing to consider the Graham-Cassidy-Heller-Johnson proposal,
September 25, 2017
Dear Senate Finance Committee Members,
I write to express my deep opposition to the Graham-Cassidy-Heller-
Johnson proposal. The sponsors of this proposal vowed that it would
replace the ACA with something better and more affordable--yet it fails
miserably in all respects. I demand a full and fair hearing on this
legislation after it has been analyzed by the Congressional Budget
Office (CBO). The last bill scored by the CBO had an approval rating of
12%, yet this bill is moving forward and is even worse than the last
bill scored. The proposal introduces pre-existing condition exclusions,
limits essential health services, and reduces the affordability of
health insurance. This is unacceptable.
The Graham-Cassidy-Heller-Johnson proposal will price ordinary
Americans out of any insurance market, returning to the days when a
cancer patient who couldn't work couldn't access health care; when a
person with asthma couldn't afford health insurance due to a pre-
existing condition; when a person working a full-time job couldn't
afford health insurance. This is not what Americans want.
Millions of elderly individuals and people with disabilities rely on
traditional Medicaid for their lives, well-being, and independence.
Medicaid saves the lives of people with disabilities who rely on things
like tracheotomy care, nursing care, dialysis, cancer treatments,
occupational therapy, speech therapy, life-saving medications, durable
medical equipment, and more to work. These people are our family
members, our neighbors, our coworkers, and our friends. We are the
wealthiest country in the world. We can and should provide Medicaid for
the elderly and people with disabilities.
This proposal will impact pregnant women and children, who are insured
by Medicaid in high numbers. In Wisconsin, 28% of all children are
covered by Medicaid. Nearly half of all US births are covered by
Medicaid. For many children with disabilities and extensive health care
needs, Medicaid is crucial--and cutting it puts children's lives at
risk. Children who receive regular health care to treat things like
asthma, diabetes, and treatable medical problems fare better in school,
miss fewer days of school, are more likely to graduate, and earn higher
wages than those without health care. Taking away their health care
thus also negatively impacts our economy.
I am submitting this testimony to the committee to ensure that it is
entered into the official record of these proceedings. I want the
record of this committee to show that those who voted for this proposal
were fully aware of its devastating and destructive impact despite
being told by millions of American citizens that this is not what we
want.
Sincerely,
Shawn M. Steen
______
Letter Submitted by Earline Thomas
September 22, 2017
U.S. Senate
Committee on Finance
Dirksen Senate Office Bldg.
Washington, DC 20510-6200
Re: Hearing to consider the Graham-Cassidy-Heller-Johnson proposal,
September 25, 2017
Senator Hatch and Republican members of the Senate Finance Committee:
I would like to offer my testimony for the Graham-Cassidy-Heller-
Johnson proposal. Please include my letter in the record for this
hearing.
Obamacare probably saved my life. Now you, an affluent U.S.
Senator, want to take my lifeline away. Why? For more campaign funds
from richer than rich contributors? To fall in rank with GOP party
lines that are driven by corporations, agencies, and individuals that
control your campaign purse strings? To satisfy campaign promises that
were never made? You did not promise to take away medical care or
Medicaid! Have you totally lost your moral guidance?
When was the last time you visited sick children dependent on
Medicaid? When did you last talk with a senior dependent on Medicaid
for their care? When did you last visit a homeless veteran who cannot
get proper housing, transportation or medical care? When did you get
turned away from medical care because you could not afford it? When did
you have to choose between insurance and other necessities?
When my seeming small insignificant injury healed over it looked
like a blood blister on my arm. It was not painful, not in my direct
line of sight and easy to ignore. After a few months it was still
there, but not noticeable if I wore a blouse with sleeves. My partner
and a neighbor convinced me to have it looked at so I went to a
dermatologist because I had insurance. My partner had an appointment
with her primary care physician the next day. They physician suggested
he could remove it surgically. It turned out to be a deep melanoma and
had just started to invade the lymph system.
Follow-up surgery took out more tissue and I now have a cancer
diagnosis of IIIB. If I had waited any longer to see a physician, the
cancer would have been stage IV, and I likely would have died. If I
didn't have insurance at the time, I could not have been convinced to
see a doctor until I became sick. All I had was a strange-looking
lesion on my arm that was not painful.
The follow-up surgeries, scans and appointments over the past 2
years would have been financially difficult. But now the proposed
changes in health care by the BCRA, the repeal of ACA, the Graham-
Cassidy bill and other attempts to destroy affordable health insurance,
would take away my ability to continue to get good care. The costs of a
metastatic cancer diagnosis will be approximately $150,000.00 per year
for this pre-existing condition. No one can afford that type of
insurance premium.
Your constituents are quite aware that you are trying to pass a
bill that will destroy their chance to get good medical care, and that
you have no concerns for their health or their financial stability.
They know you are voting for your wealthy supporters and not for the
families of your states. They will remember in the 2018 election year
that you took away healthcare from their families. They will remember
in election year 2020 and 2022 that you tried undermine AND harm the
health of the nation. You as a group and as individuals will be shamed
by the people of this great nation for the harm you are purposely
inflicting.
Sincerely,
Earline Thomas
______
Letter Submitted by Emily Todebush
U.S. Senate
Committee on Finance
Dirksen Senate Office Building
Washington, DC 20510-6200
Re: Graham-Cassidy-Heller-Johnson proposal hearing, September 25, 2017
The Honorable Orrin Hatch, Chairman of the Senate Finance Committee and
the other distinguished members of this committee:
It is with heavy heart that I submit my testimony in opposition of the
Graham-
Cassidy-Heller-Johnson proposal. I would like my written testimony to
be included in the hearing record.
Birthdays, phone numbers, addresses. Our lives are oftentimes summed up
by a series of numbers that help tell the story of where we came from
and where we're going. On February 26, 2013, I added another number to
my collection: 340, the international diagnostic code for multiple
sclerosis. I was 27-years-old.
Let me back up.
In early October 2012, I was experiencing a very specific pain behind
my right eye. The pain was excruciating and hurt every time I moved my
eye. Have you ever wondered how much you move your eye in a 10-minute
span? Spoiler alert: It's a lot.
I had started a new job just 60 days earlier and for 30 more days, I
was only covered by a ``catastrophic'' insurance plan, which meant I
could only see a doctor in the ER and my deductible was $10,000. No
other doctor's visits were covered. Not exactly generous, but I was a
healthy twenty-something. What could go wrong?
Because I am not rich, I had to wait until my new insurance kicked in
before I could see a doctor. Once I was finally covered and finally
seeking help, I spent months dealing with neurological symptoms that
evolved from eye pain to total numbness and tingling along the right
side of my body to difficulty walking. I would oftentimes lay awake at
night thinking how in the world I would get to work if I couldn't walk
reliably. My life was changing in front of me, but I wasn't in control
of any of it.
My experience is no different than anyone else with a pre-existing
condition. Whether it's MS or cancer, the reality is the same; you are
completely at the mercy of your insurance provider. That's only a
portion of what makes Graham-Cassidy-Heller-Johnson so terrifying.
Here's why it matters to me and everyone else with a pre-existing
condition.
Before implementation of the Affordable Care Act, insurance companies
were allowed to impose a ``lifetime maximum'' to your policy. Those
lifetime maximums were oftentimes $1,000,000, which is a number big
enough that it seems unlikely you'll ever reach it. Unlikely unless
you've experienced a serious health episode, that is. The Affordable
Care Act outlawed lifetime maximums, but this bill reinstates that
lifetime maximum provision.
Why does that matter?
Take me for example. My health insurance policy is charged more than
$100,000 a year for my cost of care. Of that $100,000 a year, $81,600
of that goes to pay for my disease-modifying drug, whose sole purpose
is to slow and delay the ability for MS to destroy my central nervous
system. If you are unfamiliar with the disease, I should tell you that
the unpredictable way this disease attacks makes it very complicated
for me to plan my future. This disease in its progression will
deteriorate my brain and spinal cord, potentially causing paralysis and
a whole host of other disabilities. Without my medication, MS would
attack my body at will, and I would be a prisoner in my own body. And,
if you used $100,000 as an annual benchmark, I would exceed my
insurance benefits in 10 years, when I will be just 42-years old.
At that time, my insurance company will be allowed drop me. That would
force me to look for a new insurance plan. Because I have a pre-
existing condition, insurance companies could deny me coverage outright
or they would be able to charge me unaffordable insurance premiums,
forcing me to go without. So, to those of you who roll your eyes when
you hear someone on the news saying that there are people who might die
without the Affordable Care Act: please, remember this story. MS does
not provide a quick death, instead causing a slow breakdown of function
and body processes that is both heartbreaking to watch and agonizing to
experience.
In addition to removing protections for pre-existing conditions, this
bill strips what are considered ``essential health benefits,'' which
means that my insurance carrier wouldn't have to cover any of my
doctor's visits, lab tests, MRIs, or prescription drugs that are
critical to my care.
You see, my life is all about numbers. I am now part of an exclusive
club; just one of the tens of millions of Americans who could lose
their insurance coverage if you pass this disastrous legislation.
How a country cares for its most vulnerable population says a lot about
who we are as a nation, about our character. The healthcare debate has
always been about something more than politics. It's about doing what's
right for the people who don't have a voice. I choose to speak out
about healthcare not to point out how sick I am, but to illustrate how
sick I am not, and that is in large part thanks to the Affordable Care
Act.
Since I was a very little girl, I have had a tremendous and
overwhelming love for my country. I believe that while our union is not
perfect, when we gather to debate, we bear witness to the enduring
strength of our constitution. We affirm the promise of democracy. We
are celebrating that our nation is truly an idea that is unique;
carefully thought out and a masterpiece in the making. It demonstrates
that what makes this country exceptional is our allegiance to an idea,
a constitution, which our founders articulated many centuries ago. Our
government was carefully designed as a government for, by, and of the
people. It is all our call to duty to bridge the meaning of the words
written as a Declaration of Independence with the realities of our
time; for history tells us that while these truths may be self-evident,
they've never been self-executing.
I am among the 32 million Americans who will be hurt by this bill.
Because I live in Washington, DC, I do not have a Senator to call. I
don't have representation in my own government; someone to plead my
case to. Instead, I am writing you a letter, to be submitted into the
record of a hearing that I am not allowed to attend, much less testify
in person.
I have a face. I am a person. I am someone's daughter, sister, grand-
daughter, niece, aunt, significant other, and friend. I want to live a
full and prosperous life. I want to grow old. I want to feel the sun on
my face and breathe a sigh of relief that the Congress in which I have
no say in electing, is somehow remembering that I am a person too.
Someone whose health hangs in the balance of this hearing, this vote,
and this Congress.
I respectfully ask that this bill be pulled from consideration and that
both parties work together to fix the flaws in the Affordable Care Act.
In good health,
Emily Todebush
Washington, DC, by way of the great State of Michigan
______
Trust for America's Health
1730 M Street, NW, Suite 900
Washington, DC 20036
(t) 202-223-9870
(f) 202-223-9871
www.healthyamericans.org
September 22, 2017
U.S. Senate
Committee on Finance
Dirksen Senate Office Building
Washington, DC 20510-6200
RE: Hearing to consider the Graham-Cassidy-Heller-Johnson
proposal, September 25, 2017
Dear Chairman Hatch and Ranking Member Wyden:
On behalf of Trust for America's Health, a non-profit, non-partisan
organization dedicated to improving the health of every American, I am
writing to voice our strong opposition to the Graham-Cassidy-Heller-
Johnson amendment (#1030) to the American Health Care Act (H.R. 1628)
and to any legislation that would eliminate the Prevention and Public
Health Fund (Prevention Fund). We urge Senators to work together in a
bipartisan manner to ensure that Americans have access to high quality,
affordable health care, including clinical preventive services, and to
strengthen the public health system so that illnesses, injuries and
needless deaths can be avoided.
Although we do not yet have a score from the Congressional Budget
Office (CBO), the Graham-Cassidy proposal would dramatically increase
the number of uninsured Americans by an estimated 32 million Americans,
according to an analysis by the Center on Budget and Policy Priorities.
It also would eliminate $15.1 billion in current and future public
health funding (FY19-FY28). This will threaten the ability of the
Center for Disease Control and Prevention (CDC) to protect Americans'
health and slash lifesaving investments in states by more than $3
billion over 5 years alone. The result will be American people becoming
sicker and poorer. It will impede our ability to respond to and recover
from natural disasters such as Hurricanes Harvey and Irma. We will
likely see more opioid overdoses, increases in infant mortality and
innumerable other preventable health issues, all of which add up to
elevated healthcare costs.
We are particularly concerned about the impact on those covered under
Medicaid. The same analysis indicates that this proposal would cut
Medicaid funding for all but 12 states, with those states with Medicaid
expansion populations being particularly disadvantaged. Reductions in
Medicaid enrollment would severely restrict access to health care
services, especially for those with limited incomes. By eliminating
protections for those with pre-existing conditions, Americans who have
faced or are currently facing illness will be particularly prone to
higher premiums and subsequently higher rates of uninsured. Without
affordable insurance coverage, we will see increased rates of
preventable illnesses, injuries and deaths.
Coverage is crucially important, but we also want to highlight the
consequences of repealing the Prevention Fund, which makes up 12
percent of the CDC budget. Of that investment, $625 million directly
supports state and local public health efforts. This legislation would
eliminate the Prevention Fund as of October 2018 (FY19). This would
devastate the CDC budget and would wreak havoc on our efforts to reduce
chronic disease rates, immunize our children and prepare the public
health system to address infectious disease outbreaks and other
threats.
The United States spends more than $3 trillion annually on health care,
but directs just 3 percent of that toward preventing illness in the
first place. Public health funding is already insufficient to meet
existing needs, and public health departments struggle every time a new
epidemic emerges, as we saw last year with the emergence of the Zika
virus. This leaves Americans unnecessarily vulnerable to preventable
health problems, ranging from major disease outbreaks and bioterrorism
threats to diabetes and opioid misuse.
We don't know where or when the next outbreak will come and we can't
wait until a crisis hits to begin investing in public health. Keeping
Americans healthier would significantly drive down trips to the
doctor's office or emergency room, safeguard Americans against
epidemics, and reduce healthcare costs. Finally, we have attached below
for your consideration a letter addressed to Senate leadership dated
June 26, 2017 and signed by over 580 organizations, expressing their
opposition to repealing the Prevention and Public Health Fund. We urge
you to oppose this legislation. Thank you for your consideration.
Sincerely,
John Auerbach
President and CEO
______
June 26, 2017
The Honorable Mitch McConnell
Senate Majority Leader
U.S. Senate
Washington, DC 20510
The Honorable Charles Schumer
Senate Minority Leader
U.S. Senate
Washington, DC 20510
Dear Majority Leader McConnell and Minority Leader Schumer:
On behalf of the more than 580 undersigned organizations, we are
writing to warn of the dire consequences of repealing the Prevention
and Public Health Fund (the Prevention Fund), which is repealed by the
Better Care Reconciliation Act (H.R. 1628) at the start of FY 2018.
Repealing the Prevention Fund without a corresponding increase in the
allocation for the Labor-Health and Human Services-Education
appropriations bill would leave a funding gap for essential public
health programs, and could also foretell substantial cuts for other
critical programs funded in the bill. As the Senate continues work on
its version of health reform, we urge you to leave the Prevention and
Public Health Fund in place.
Today, more than 12 percent of the Centers for Disease Control and
Prevention (CDC) budget is supplied through Prevention Fund
investments. This includes core public health programs that provide
essential funds to help states keep communities healthy and safe, such
as the 317 immunization program, epidemiology and laboratory capacity
grants, the entire Preventive Health and Health Services (Prevent)
Block Grant program, cancer screenings, chronic disease prevention and
other critically important programs. For example, the Prevent Block
Grant provides all 50 states, the District of Columbia, 2 American
Indian tribes, and 8 U.S. territories with flexible funding to address
their unique public health issues at the state and community level.
Despite the growing and geographically disparate burden of largely
preventable diseases, health threats such as the opioid epidemic, and
emerging infectious disease outbreaks such as the Zika virus, federal
disease prevention and public health programs remain critically
underfunded. Public health spending is still below pre-
recession levels, having remained relatively flat for years. The CDC's
budget authority has actually decreased by 11.4 percent since FY 2010
adjusted for inflation, and the Prevention Fund has helped to make up
the difference.
Discretionary programs, including public health, education, and job
training programs funded through the Labor-Health and Human Services-
Education (LHHS) appropriations spending bill have been cut
dramatically and disproportionately in recent years as lawmakers have
worked to reduce the deficit, even though experts across the political
spectrum agree these programs are not a driving factor behind our
nation's mid- and long-term fiscal challenges. Eliminating the
Prevention Fund would be disastrous to the CDC budget and programs, and
to the LHHS bill as a whole, leaving a nearly $1 billion budget hole
which would be impossible to fill under current discretionary spending
caps.
Funding prevention not only saves lives but it saves money. A
comprehensive study of evidence based prevention programs found that
every dollar invested yields $5.60 in savings. There are many
provisions of the Affordable Care Act aimed at promoting health and
prevention, but the Prevention Fund is particularly important--a
dedicated investment in prevention and public health activities to
counteract the much larger bill--$3.2 trillion and growing--we pay
every year as a country to treat illness and disease.
We urge you to maintain funding made possible by the Prevention and
Public Health Fund and safeguard funding for the CDC and other programs
under the Labor-HHS-Education spending bill.
Sincerely,
2Morrow, Inc. American College of Cardiology
1,000 Days American College of Clinical
Pharmacy
1965 American College of Occupational
and Environmental Medicine
Ability360 American College of Preventive
Medicine
Academy of Geriatric Physical
Therapy American College of Sports Medicine
Academy of Nutrition and Dietetics American Council on Exercise
Action for Healthy Kids (AFHK) American Diabetes Association
Active Living By Design American Federation of State,
County, and Municipal Employees
Active Transportation Alliance American Federation of Teachers
Ad Hoc Group for Medical Research American Foundation for Suicide
Prevention
ADAP Advocacy Association (aaa+) American Heart Association
Addiction Connections Resource American Immunization Registry
Association
Adult Congenital Heart Association American Indian/Alaska Native/
Native Hawaiian APHA Caucus
Advancement Project California The American Academy of HIV
Medicine
Advocate Good Shepherd Hospital American College of Occupational
and Environmental Medicine
Advocates for Better Children's
Diets American Lung Association
African American Health Alliance American Medical Student
Association
AIDS Alliance for Women, Infants,
Children, Youth, and Families American Organization of Nurse
Executives
The AIDS Institute American Psychological Association
AIDS Research Consortium of Atlanta American Public Health Association
AIDS United American School Health Association
Alabaster American Sexual Health Association
Allamakee County Public Health American Society for Nutrition
American Academy of HIV Medicine American Society of Hematology
American Academy of Pediatrics American Society of Tropical
Medicine and Hygiene
American Association for Dental
Research American STD Association
American Association for the Study
of Liver Diseases American Thoracic Society
American Association of Colleges of
Nursing Ann and Robert H. Lurie Foundation
American Association of Colleges of
Pharmacy APICAT for Healthy Communities
American Association of
Naturopathic Physicians APLA Health
American Association of
Neuromuscular and Electrodiagnostic
Medicine The Arc
American Association on Health and
Disability Arizona Center for Law in the
Public Interest
American Cancer Society Cancer
Action Network The Bronx Health Link
Arizona Health Care Association Bronx Health REACH
Arizona Medical Association California Food Policy Advocates
The Arizona Partnership for
Immunization California Pan-Ethnic Health
Network
Arizona Public Health Association California Public Health
Association-North
Arizona Rural Health Association California State Association of
Counties
Arkansas Public Health Association California WIC Association
Asian and Pacific Islander American
Health Forum Cambridge Health Alliance
Asian Services In Action Campaign for Tobacco-Free Kids
Association for Clinical and
Translational Science Camptonville Community Partnership
Association for Prevention Teaching
and Research Canary Health
Association for Professionals in
Infection Control and Epidemiology Cancer Council of the Pacific
Islands
Association of Accredited
Naturopathic Medical Colleges Cancer Prevention and Treatment
Fund
Association of Accredited Public
Health Programs Canyon Ranch Center for Prevention
and Health Promotion
Association of American Cancer
Institutes The Cave Institute
Association of American Medical
Colleges Cedar County Public Health
Association of Community Health
Nursing Educators Center for Behavioral Epidemiology
and Community Health
Association of Maternal and Child
Health Programs Center for Health and Learning
Association of Montana Public
Health Officials Center for Health Promotion and
Disease Prevention
Association of Public Health
Laboratories Center for Science in the Public
Interest
Association of Public Health Nurses Center in the Park
Association of Reproductive Health
Professionals Center for Popular Democracy
Association of Schools and Programs
of Public Health Central California Asthma
Collaborative
Association of State and
Territorial Health Officials Central Jersey Family Health
Consortium
Association of State Public Health
Nutritionists Central Michigan District Health
Department
Association of University Centers
on Disabilities Central Michigan Regional Rural
Health Network
Asthma and Allergy Foundation of
America Centralina Area Agency on Aging
Atrius Health Centro Multicultural La Familia
Authority Health Cerro Gordo County Department of
Public Health
B'more Mobile Chalk Talk Science Project
Barnes ON THE MOVE Partnership ChangeLab Solutions
Behavioral Health Leadership
Institute Chautauqua County Department of
Health and Human Services
Benzie Leelanau District Health
Department Chicago Commons
Berean Wellness and Community
Support Center Childhood Obesity Prevention
Coalition of Washington State
Big Cities Health Coalition Children and Adults with Attention
Deficit Hyperactivity Disorder
(CHADD)
Black Women's Health Imperative Children's Action Alliance
Boston Alliance for Community
Health Children's Environmental Health
Network
Boston Public Health Commission Children's Health Fund
Boston Senior Home Care Children's Mental Health Network
Boston University School of Public
Health City-County Health District
Boulder County (CO) Public Health Clinica Sierra Vista
Boys and Girls Clubs of America Clinical Research Forum
Coalition for Healthy School Food Coalition for Clinical and
Translational Science
Coconino County Public Health
Services District Coalition for Health Funding
College of Public Health and Human
Sciences District Health Department 2 and 4
(West Branch, MI)
Oregon State University Diversified Resources Group
Colorado Association of Local
Public Health Officials Doctors for America
Colorado Association of School
Nurses Dorchester County Health Department
Colorado Children's Immunization
Coalition Duxbury Council on Aging
Colorado Public Health Association Dystonia Medical Research
Foundation
Columbia County (NY) Health
Department Early Impact Virginia
Commissioned Officers Association
of the U.S. Public Health Service,
Inc. (COA) East Bay Agency for Children
CommonHealth ACTION Edna Bennett Pierce Prevention
Center, Penn State University
Community Access National Network
(CANN) Ehrens Consulting
Community Catalyst Elder Options
Community Clinic Consortium Elder Services of the Merrimack
Valley, Inc.
Community Health Councils Elder Services of Worcester Area,
Inc.
Community Health Initiative Napa
County (CA) Element Health, Inc.
Community Health Improvement
Partners Emory University
Connecticut Directors of Health
Association Endocrine Society
Connecticut Public Health
Association Enhance Asian Community on Health
Conrad House, Inc. Eradicating the School-to-Prison
Pipeline Foundation, Inc.
The Consortium Essential Access Health
Contact Wellness Foundation Essex County (NY) Health Department
Cook County (IL) Department of
Public Health ETA Sigma Gamma
Cooley's Anemia Foundation Evidence-Based Leadership Council
COPD Foundation Fairhill Partners
Council for Diabetes Prevention Family Services Agency of Santa
Barbara (CA) County
Council of Mexican Federations in
North America The Family Van: Harvard Medical
School
Council of State and Territorial
Epidemiologists Fathers and Families of San Joaquin
Council on Aging--Chicopee, MA Fayette County Health Department
County Health Executives
Association of California Feeling Good MN
County of San Diego Health and
Human Services Agency First in Families of North Carolina
The Crohn's and Colitis Foundation
of America Florida Breastfeeding Coalition
Cultiva La Salud The Food Trust
Delaware Academy of Medicine/
Delaware Public Health Association Forest Grove Public Schools Region
6 Regional Prevention Coordinators
Delaware County Office for the
Aging Foundation for Healthy Generations
Delaware Public Health Association Fund for Public Health in New York
City
Denver Public Health Futures Without Violence
Des Ahrens Lactation Consulting Gallatin City-County Health
Department
Detroit Public Health STD Clinic Gay and Lesbian Medical Association
Diabetes Center for Improvement GBS/CIDP Foundation International
Digestive Disease National
Coalition George Washington University Cancer
Center
Dignity Health Georgia Society for Public Health
Education
Directors of Health Promotion and
Education Global Liver Institute
District Health Department #10
(Tampa, FL) Grand Traverse County Health
Department Greater Holyoke YMCA
Healing Touch Massage The Greenlining Institute
Health Care Foundation of Greater
Kansas City Harrison County (IA)
Health Connect of South Dakota Home and Public Health
Health Department of Northwest
Michigan Hawaii Public Health Association
Healthy Living Collaborative of
Southwest Washington Hawaii Public Health Institute
Health Promotion Council of
Southeastern Pennsylvania, Inc. Interstitial Cystitis Foundation
Health Resources in Action Inter-Tribal Council of Michigan
Healthcare Ready Iowa Public Health Association
Healthy Communities Coalition Jefferson County Public Health
Healthy Living Cape Cod Jeffrey Modell Foundation
Healthy Oxford Hills John Peter Smith Health Network
Healthy Schools Campaign Johns Hopkins Center for Health
Security
Healthy Teen Network Johns Hopkins University Institute
for Health and Productivity Studies
Healthy Weight Partnership Joy-Southfield Community
Development Corp
Hemophilia Council of California Kalusugan Community Services
Hemophilia Foundation of Southern
California Kansas Breastfeeding Coalition
Hepatitis B Foundation Kentucky Voices for Health
Hepatitis Foundation International Khmer Health Advocates
Heritage Health and Housing KL Startups
Hispanic Health Initiatives, Inc. Kossuth County Public Health
HIV Medicine Association La Alianza Hispana
HLN Consulting, LLC Lake County Health Department and
Community Health Center
Hogg Foundation for Mental Health Lakeshore Foundation
Home Care Alliance of MA Latino Coalition for a Healthy
California
Human Impact Partners The Latino Health Insurance
Program, Inc.
Human Rights Campaign Latino Public Health Network at
Hopkins
Idaho Immunization Coalition Laurie M. Tisch Center for Food,
Education, and Policy, Teachers
College, Columbia University
Idaho Public Health Association Lawrence-Douglas County Health
Department
Idaho Walk Bike Alliance League of American Bicyclists
Illinois Public Health Institute Levine Senior Center
Immunize Nevada LISC New York City
Impetus--Let's Get Started, LLC LiveWell Longmont
Indiana Public Health Association LiveWell Luzerne
Infectious Diseases Society of
America Liver Health Initiative
Institute for Community and
Collaborative Health Local Public Health Association of
Minnesota
Institute for Health and
Productivity Studies, Johns Hopkins
Bloomberg School of Public Health Los Angeles County Department of
Public Health
Institute for Public Health
Innovation The Los Angeles Trust for
Children's Health
Institute of Social Medicine and
Community Health Louisiana Public Health Association
Intermountain Public Health
Consulting, LLC Louisiana Public Health Institute
International Board of Lactation
Consultant Examiners Lung Cancer Alliance
International Certification and
Reciprocity Consortium Madera Coalition for Community
Justice
International Foundation for
Functional Gastrointestinal
Disorders Maine Public Health Association
International Society for Disease
Surveillance MaineHealth
International Valley Health
Institute March of Dimes
Medicines360 The Marfan Foundation
Meharry Medical College Maricopa County Department of
Public Health
Men's Health Caucus Maricopa Integrated Health System
Mennin Consulting and Associates Maryland Partnership for Prevention
Mental Health America of Arizona Maryland Public Health Organization
METAvivor Massachusetts Public Health
Association
Metropolitan Area Planning Council Master Trainer
Metropolitan Chicago Breast Cancer
Task Force Matter of Balance
Michigan Association for Local
Public Health Meals on Wheels
Michigan Breastfeeding Network National Blood Clot Alliance
MIKE Program National Center for Disaster
Preparedness
Minneapolis Health Department National Center for Health Care
Minnesota Academy of Nutrition and
Dietetics National Center for Transgender
Equality
Minnesota Public Health Association The National Commission for Health
Education Credentialing, Inc.
Mississippi Public Health
Association National Coalition for Promoting
Physical Activity
Missouri Association of Area
Agencies on Aging National Coalition of STD Directors
MJH Grant Consulting National Coalition on Health Care
Monona County Public Health National Collaborative for Health
Equity
Montana Primary Care Association The National Consumer Voice for
Quality
Montana Public Health Association National Consumers League Long-Term
Care
Montgomery County Health Department National Council for Behavioral
Health
Montrose County School District National Council on Aging
Morehouse School of Medicine National Environmental Health
Association
Mother and Child Health Coalition National Family Planning and
Reproductive Health Association
Multicultural Family Center National Forum for Heart Disease
and Stroke Prevention
My Brother's Keeper, Inc. National Foundation for Infectious
Diseases
NAATPN, Inc. National Health Care for the
Homeless Council
NAPHSIS: National Association for
Public Health Statistics and
Information Systems National Healthy Start Association
Nashville CARES National Hemophilia Foundation
National AHEC Organization National Hispanic Medical
Association
National Alliance on Mental Illness National Institute for Children's
Health Quality
National Alliance of State and
Territorial AIDS Directors National Latino Network of Casa de
Esperanza
National Alopecia Areata Foundation National Physician's Alliance
National Association for Health and
Fitness National Network of Public Health
Institutes
National Association of Area
Agencies on Aging National Prevention Science
Coalition
National Association of Chronic
Disease Directors National Recreation and Park
Association
National Association of Counties National Resource Center on
Domestic Violence
National Association of County and
City Health Officials The National Viral Hepatitis
Roundtable
National Association of Perinatal
Social Workers National WIC Association
National Association of School
Nurses National Women's Health Network
National Association of Social
Workers Native Health
National Association of State
Alcohol and Drug Abuse Directors NC SOPHE Advocacy Committee
National Birth Defects Prevention
Network Nebraska Association of Local
Health Directors
National Birth Equity Collaborative Nemours Children's Health System
National Black Justice Coalition NephCure Kidney International
NICHQ (National Institute for
Children's Health Quality) NETWORK Lobby for Catholic Social
Justice
NIRSA: Leaders in Collegiate
Recreation Nevada Public Health Association
NJSOPHE New England Wellness Foundation
NJ YMCA State Alliance New Jersey Public Health
Association
NMAC New Mexico Public Health
Association
North American Quitline Consortium The New York Academy of Medicine
North Carolina Alliance for Health New York State Association of
County Health Officials
North Carolina Citizens for Public
Health Newington Senior and Disabled
Center
North Dakota Public Health
Association Public Health Foundation
Northern Illinois Public Health
Consortium Public Health Institute
Nurses of South Carolina Public Health Solutions
Nursing Students for Sexual and
Reproductive Health Pulmonary Fibrosis Advocates
OASIS Institute Pulmonary Hypertension Association
Ohio Public Health Association PureView Health Center
Oklahoma Public Health Association Quality Home Care Services
Olympic Area Agency on Aging Racial and Ethnic Health
Disparities Coalition
ON THE MOVE, a Community Public
Health Partnership Rails-to-Trails Conservancy
Ontario County (NY) Public Health Raising Women's Voices for the
Health Care We Need
Oregon Public Health Association Redstone Global Center for
Prevention and Wellness
Oregon State University Region 9 Education Cooperative
Origins FTD, Inc. Research!America
Out2Enroll Respiratory Health Association
Partners for a Healthier Community Retrofit
Partners in Care Foundation RiverStone Health
PATHS Education Worldwide Rural AIDS Action Network
Peer Health Exchange Rural Center for AIDS/STD
Prevention at the IU School of
Public Health Bloomington
Peggy Lillis Foundation S2AY Rural Health Network, Inc.
Personal Assistance Services
Council Sacramento Black Child Development
Institute
Philly Breastfeeds Safe and Healthy Communities
Planned Parenthood Federation of
America Safe Kids Worldwide
Polk County (WI) Health Department Safe Routes to School National
Partnership
Presence Mercy Medical Center
Health Institute Safe States Alliance
Prevent Blindness Saint Anthony Hospital
Prevent Cancer Foundation Salud de Paloma
Prevention Institute San Francisco AIDS Foundation
Preventive Cardiovascular Nurses
Association Sarah Samuels Center for Public
Health Research and Evaluation
Primary Care Development
Corporation Self-Management Resource Center
Primary Care Medicine and Public
Health Synergy School-Based Health Alliance
Prism Health North Texas Scleroderma Foundation
Project Inform SCP Partners
Project Mend-A-House Second Harvest Food Bank Santa Cruz
County
Promoting Healthy Self-Management Resource Center
Protecting Arizona's Family
Coalition Senior Citizen Services of Greater
Tarrant County Inc.
Public Health Advocates Senior Resources--Agency on Aging
Public Health Association of
Nebraska Senior Services of Snohomish County
Public Health Association of New
York City Senior Services of Southeastern
Virginia
Public Health Delta and Menominee
Counties SeniorsPlus
The Society for Healthcare
Epidemiology of America Sexuality Information and Education
Council of the U.S.
Society for Public Health Education Shelby County Schools Coordinated
School Health
Society for the Advancement of
Violence and Injury Research
(SAVIR) Shoals Community Clinic
Society of Behavioral Medicine Sickle Cell Disease Association/
PDVC
The Society for Healthcare
Epidemiology of America Sigma Xi, The Scientific Research
Honor Society
Society of State Leaders of Health
and Physical Education Sleep Research Society
South Alabama Regional Planning
Commission Virginia Public Health Association
South Carolina Tobacco-Free
Collaborative Walk San Francisco
Southeast Ohio Breastfeeding
Coalition WalkBoston
Southern AIDS Coalition The Wall Las Memorias Project
Southern California Public Health
Association Washington State Association of
Local Public Health Officials
(WSALPHO)
Southern California Society for
Public Health Education Washington State Public Health
Association
Southern HIV/AIDS Strategy
Initiative (SASI) Wayne State University Center for
Health and Community Impact
Southwest Human Development, Inc. Wellco
SparksInitiatives WellGiG
Spina Bifida Association Wellness Institute of Greater
Buffalo
Spokane Shrinking Violet Society West Valley Neighborhoods Coalition
St. Clair County Health Department Western Illinois Area Agency on
Aging
Street Level Health Project Western North Carolina AIDS Project
Stewart Memorial Community Hospital Wholesome Wave
Susan G. Komen Wilkes-Barre Family YMCA
Tacoma-Pierce County (WA) Health
Department Winnesehiek County Board of Health
Tennessee Public Health Association Wisconsin Institute for Healthy
Aging
Think Bicycles of Johnson County Wisconsin Public Health Association
Three Rivers District Home Health WithinReach
Thrive At Life: Working Solutions Wolfson Wellness
Tomorrow Matters! WomenHeart: The National Coalition
for Women with Heart Disease
Training Resources Network, Inc. The Women's Caucus
Treatment Action Group Worksite Wellness LA
Tri County Health Department
(Greenwood Village, CO) YCat Yoga Therapy and Jnani
Chapman's Integrative Medicine
Service
Trust for America's Health Yolo County (CA) Children's
Alliance
Tuscola County Health Department Youngstown State University
Union for Reform Judaism YOUR Center
U.S. Hereditary Angioedema
Association Zero Breast Cancer
United States Breastfeeding
Committee
United Way of Tarrant County, TX
Universal Health Care Action
Network of Ohio
The University of Texas M.D.
Anderson Cancer Center
Utah Public Health Association
Valley Program for Aging Services
Vermont Public Health Association
VillageCare
Village Connect
______
UnidosUS
Raul Yzaguirre Building
1126 16th Street, NW, Suite 600
Washington, DC 20036-4845
Introduction
UnidosUS, formerly the National Council of LaRaza, is the largest
national Hispanic * civil rights and advocacy organization
in the United States. For nearly 50 years, we have worked to advance
opportunities for middle- and working-class Latino children and
families, including immigrant and mixed-status households, to achieve
the highest level of health possible. In this capacity, UnidosUS and
its Affiliate Network of nearly 300 Affiliates have worked to ensure
that all people-regardless of who they are or where they are from--have
access to affordable, quality health care.
---------------------------------------------------------------------------
* The terms ``Hispanic'' and ``Latino'' are used
interchangeably by the U.S. Census Bureau and throughout this document
to refer to persons of Mexican, Puerto Rican, Cuban, Central American,
Dominican, Spanish, and other Hispanic descent; they may be of any
race.
Advancing health equity is crucial for all Americans, including Latinos
who are still more likely to be uninsured than other Americans. The
Affordable Care Act (ACA) has helped drive us closer to health equity.
Since the implementation of this law, more than 4 million Latinos
gained coverage and the rate of uninsured Latinos plummeted to a record
low--from 43.2% in 2010 to 24.8% in 2016.\1\ Still, this progress is
fragile. While the number of uninsured Latinos has fallen dramatically
because of the ACA, in 2016, 40% of uninsured adults were Latino.\2\
Proposals that we have seen to repeal and replace the ACA would reverse
course on these historic gains and put millions of people one medical
emergency away from financial devastation.
---------------------------------------------------------------------------
\1\ The Commonwealth Fund, ``Millions More Latino Adults Are
Insured Under the Affordable Care Act'' (Washington, DC, The
Commonwealth Fund, 2017), http://www.commonwealthfund.
org/publications/blog/2017/jan/more-latino-adults-insured.
\2\ Ibid.
As evidence of our commitment to improving access to health care,
UnidosUS has published several reports on coverage gains and what the
---------------------------------------------------------------------------
ACA means to the Latino community:
``Latino Children's Coverage Reaches Historic High, But Too Many
Remain Uninsured,'' published by UnidosUS and the Georgetown Center for
Children and Families (December 2016).
``Historic Gains in Health Coverage for Hispanic Children in the
Affordable Care Act's First Year,'' published by UnidosUS and the
Georgetown Center for Children and Families (January 2016).
``Latino Health at Risk: What the American Health Care Act Means
for Latinos''--separate publications for Arizona, Colorado, Florida,
and Nevada, published by UnidosUS and FamilesUSA (June 2017).
UnidosUS strongly opposes the Graham-Cassidy-Heller-Johnson bill
(Graham-Cassidy), the latest in a long string of attempts to repeal and
replace the ACA. By some estimates, this bill would lead to at least 30
million people losing coverage, deep cuts and restructuring of the
Medicaid program, weakening or eliminating protections for people with
preexisting conditions, and skyrocket out-of-pocket costs for
consumers. It is not surprising that so many stakeholders have publicly
expressed their opposition to the bill, including a bipartisan group of
governors, all 50 state Medicaid directors, the American Academy of
Pediatrics, and America's Health Insurance Plans (AHIP). Hardworking
Americans, including Latinos, cannot afford the implications of this
bill.
This written statement will focus on the importance of the ACA program
to the Latino community, concerns with the Graham-Cassidy proposal, and
recommendations for strengthening the ACA by stabilizing the
marketplace.
The ACA Has Led to Historic Gains for Latino Coverage
Overall, the ACA has made health coverage a reality for 20 million
Americans, including 4 million nonelderly Latino adults.\3\ Since the
provisions went into effect in 2013, the positive effects have been
clear:
---------------------------------------------------------------------------
\3\ Assistant Secretary for Planning and Evaluation, ``Health
Insurance Coverage and the Affordable Care Act,'' Washington, DC, 2015.
Over 4 million Latinos, including children and young adults,
have benefited from the ACA's provisions. The ACA has provided coverage
to mostly nonelderly adults--4.2 million. It is important to note that
figure includes over 900,000 Latino young adults between the ages of 19
and 26. These young Latinos would otherwise be uninsured; but have
coverage under their parents' plan because of the ACA.\4\ Additionally,
over 600,000 Latino children have gained coverage since 2013 because of
health coverage expansions, including the ACA.\5\
---------------------------------------------------------------------------
\4\ Assistant Secretary for Planning and Evaluation, ``Report Shows
Affordable Care Act Has Expanded Insurance Coverage Among Young Adults
of All Races and Ethnicities,'' Washington, DC, 2012.
\5\ Ibid.
The ACA has brought the Latino uninsured rate down to historic
lows. Between 2013 and 2015, the overall Latino uninsured rate declined
to 16.2%, the lowest rate ever recorded.\6\ This dramatic reduction is
due, in large part, to the ACA. This law is also thought to have
influenced a similar decline in the Latino child uninsured rate--with
the largest 2-year decline on record between 2013 and 2015 (11.5%-
7.5%).\7\ This decline also brought the uninsurance rate for Latino
children to a record low.
---------------------------------------------------------------------------
\6\ U.S. Census Bureau, ``Health Insurance Coverage in the United
States: 2015,'' Current Population Reports, Washington, DC, 2016.
\7\ Georgetown Center for Children and Families and NCLR, ``Latino
Children's Coverage Reaches Historic High, But Too Many Remain
Uninsured'' (Washington, DC: Georgetown Center for Children and
Families and NCLR, 2016), http://publications.nclr.org/handle/
123456789/1672 (accessed January 2017).
States that expanded Medicaid under the ACA have experienced the
largest decline in the uninsured rate for nonelderly Latino adults. In
these states, the average uninsured rate for elderly Latino adults was
22%, compared to 36% in states that elected not to expand.\8\
California, which expanded its Medicaid program, experienced the
largest percentage point decline in the nonelderly Latino adult
uninsured rate of any state (38%-20%).\9\
---------------------------------------------------------------------------
\8\ Ibid.
\9\ Ibid.
Most Latinos know that the ACA is working. Nationwide, nearly
three out of four Latino voters (71%) believe that the ACA is working
well or mostly working well, and should remain in place.\10\ Moreover,
the August 2017 Kaiser Health Tracking Poll found that overall, most
adults (60%) thought it was a good thing that Republicans did not
repeal the ACA.
---------------------------------------------------------------------------
\10\ National Council of La Raza and Latino Decisions, Health
Policy Survey: October 12-19, 2016 (Washington, DC: NCLR and Latino
Decisions, 2016).
---------------------------------------------------------------------------
Concerns With Graham-Cassidy Bill
The Graham-Cassidy bill, the latest effort from Senate Republicans to
repeal and replace the ACA, makes one thing clear: the health and well-
being of the American people is not a priority. Instead, this bill
makes harsh cuts to fundamental health care programs like Medicaid,
while making it more difficult for working- and
middle-class Americans to access health insurance. In this spirit,
Graham-Cassidy includes the most injurious parts of previous repeal-
and-replace bills and adds other provisions that will do even more
harm. While a full score from the Congressional Budget Office (CBO)
does not exist, the CBO score of previous repeal attempts can serve as
a useful proxy of the effect this bill would have on health coverage in
2027 when all block grant funding to the states is cut off.\11\
Specifically, for the Obamacare Repeal Reconciliation Act, the CBO
estimated that 32 million people would lose coverage if funding for
state Medicaid expansion programs and premium subsidies were eliminated
by 2027. In fact, it is likely that coverage loss would be even greater
due to the addition of Medicaid per capita caps this bill imposes on
our children, seniors, and the disabled.
---------------------------------------------------------------------------
\11\ Congressional Budget Office, ``H.R. 1628 Obamacare Repeal
Reconciliation Act of 2017,'' Washington, DC, 2017, https://
www.cbo.gov/system/files/115th-congress-2017-2018/costestimate/52939-
hr1628amendment.pdf (accessed August 2017).
The Graham-Cassidy bill threatens the well-being of millions of
Americans, but stands to have a greater negative effect on the Latino
community. This bill puts everyone with Medicaid coverage, or receiving
premium subsidies in the ACA marketplace, at risk of losing access to
health coverage, or being forced to pay more for it. However, Latinos
will be disproportionately harmed by this proposal, because they are
more likely to count on the federal programs, like Medicaid and ACA
premium subsidies, which are singled out for major cuts. UnidosUS has
---------------------------------------------------------------------------
four key concerns with this harmful proposal from Senate Republicans.
The Medicaid program as we know it would end. Like other repeal
and replace bills, Graham-Cassidy would restructure and cut funding for
the rest of Medicaid, outside of the ACA's Medicaid expansion. The
proposal caps the amount of federal funding available for traditional
Medicaid beneficiaries like children, people with disabilities, and
low-income seniors. Between 2020 and 2026, Medicaid spending for the
traditional Medicaid Population will be cut by an estimated $175
billion, including by $39 billion in 2026 alone.\12\ These cuts will
force states to cut benefits, cap the number of enrollees, or both.
---------------------------------------------------------------------------
\12\ Jacob Leibenluft et al., ``Like Other ACA Repeal Bills,
Cassidy-Graham Plan Would Add Millions to Uninsured, Destabilize
Individual Market'' (Washington, DC: Center on Budget and Policy
Priorities, 2017).
---------------------------------------------------------------------------
A cap on Medicaid spending would hit Latinos the
hardest, as one-third of Latinos, including over half of all children,
count on Medicaid for health coverage.\13\
---------------------------------------------------------------------------
\13\ Kaiser Family Foundation, ``Distribution of the Nonelderly
With Medicaid by Race/
Ethnicity'' (Washington, DC: Kaiser Family Foundation, 2015), http://
kff.org/medicaid/state-indicator/distribution-by-raceethnicity-4/
?currentTimeframe=O; (accessed May 2017); and Center for American
Progress, ``Hispanic Children Receiving Health Insurance Through
Medicaid by State, 2015'' (data table, Center for American Progress,
2017).
---------------------------------------------------------------------------
Latino children, who are part of the traditional
Medicaid population, account for a majority of Medicaid/CHIP enrollees.
Over half of Latino children count on Medicaid for coverage and would
see their benefits or enrollment affected by drastic cuts.\14\
---------------------------------------------------------------------------
\14\ Annie E. Casey Foundation, ``Children who have health
insurance by health insurance type and by race and ethnicity''
(Baltimore, MD: Annie E. Casey, 2016); and Joan Alker, Tara Mancini,
and Martha Heberlein, ``Snapshot of Children's Coverage by Race and
Ethnicity'' (Washington, DC: Georgetown CCF, 2017).
The Medicaid expansion provision under the ACA and marketplace
subsidies would end. Graham-Cassidy would eliminate the ACA's Medicaid
expansion and marketplace subsidies starting in 2020. The proposal
includes cutting federal funding for state Medicaid expansion and
premium subsidies by $236 billion from 2020 to 2026 and offers smaller
and insufficient block grants. States would not be required to spend
block grant funds on lowering health care costs for low- and moderate-
income children and families; they could spend this money virtually any
way they please. Losing both provisions would leave millions of
Americans vulnerable to a coverage loss.
Eleven million Americans, including 3 million
Latinos, who gained Medicaid coverage because of state expansions,
would be at risk of losing coverage.\15\
---------------------------------------------------------------------------
\15\ National Council of La Raza analysis of U.S. Census Bureau,
``2015-2016 Annual Social and Economic Supplement, Current Population
Survey,'' Washington, DC, 2016, https://www.census.gov/programs-
surveys/cps/data-detail.html, with assistance from the Center on Budget
and Policy Priorities (CBPP); and Centers for Medicare and Medicaid
Services, ``Total Medicaid Enrollees--VIII Group Break Out Report''
(Washington, DC: U.S. Department of Health and Human Services, 2016),
https://www.medicaid.gov/medicaid/program-information/downloads/cms-64-
enrollment-report-jan-mar-2016.pdf.
---------------------------------------------------------------------------
Nearly 9 million Americans, including most
Latinos, who use premium subsidies to purchase individual marketplace
coverage, would be at risk of losing coverage.\16\
---------------------------------------------------------------------------
\16\ CMS, ``2017 Marketplace State-Level Open Enrollment Public Use
File,'' downloaded from https://www.cms.gov/Research-Statistics-Data-
and-Systems/Statistics-Trends-and-Reports/Marketplace-Products/
Plan_Selection_ZIP.html (accessed June 2017).
Graham-Cassidy shifts federal funds from Medicaid expansion
states to nonexpansion states. Under the proposed block grant
structure, overall funding for Medicaid expansion and subsidies will be
cut, but in 2021, reduced federal funding would be redistributed across
states. The allotment would be based on their share of low-income
residents rather than actual spending. This means that over time,
states that expanded Medicaid and effectively enrolled citizens in the
ACA's health insurance marketplace would be punished, including states
with large Latino populations, like California, Florida, and New
York.\17\ While all states will see reductions over time, at least
initially, states that did not expand or work to enroll low-income
people would see less damaging cuts or even increased funding
initially. In all, 36 states, plus DC, would face net federal funding
cuts in 2021. In the long run, every state will face net funding cuts
when block grant funding ends after 2026.\18\
---------------------------------------------------------------------------
\17\ Jacob Leibenluft et al., ``Like Other ACA Repeal Bills,
Cassidy-Graham Plan Would Add Millions to Uninsured, Destabilize
Individual Market'' (Washington, DC: Center on Budget and Policy
Priorities, 2017).
\18\ Ibid.
States that lose the most federal funds for Medicaid and premium
subsidies include states with significant Latino populations like
Arizona, California, Colorado, Florida, New York, and Nevada.
A total of 9.2 million Latinos are enrolled in
Medicaid coverage in these states.\19\
---------------------------------------------------------------------------
\19\ Kaiser Family Foundation, ``Distribution of the Nonelderly
With Medicaid by Race/
Ethnicity'' (Washington, DC: Kaiser Family Foundation, 2015), http://
kff.org/medicaid/state-indicator/distribution-by-raceethnicity-4/
?currentTimeframe=O; (accessed May 2017).
---------------------------------------------------------------------------
California stands to lose the most with a $27.8
billion cut in federal funding for health care costs and covering low-
and moderate-income people by 2026. Other states will face
significantly reduced funding as well: New York by $18.9 billion,
Florida by $2.7 billion, Arizona by $1.6 billion, Colorado by $823
million, and Nevada by $639 million.\20\
---------------------------------------------------------------------------
\20\ Jacob Leibenluft et al., ``Like Other ACA Repeal Bills,
Cassidy-Graham Plan Would Add Millions to Uninsured, Destabilize
Individual Market'' (Washington, DC: Center on Budget and Policy
Priorities, 2017).
Graham-Cassidy weakens consumer protections under the ACA,
including those for people with preexisting conditions. This bill would
allow states to waive the ACA's prohibition against charging higher
premiums based on the existence of health conditions or health status.
The U.S. Department of Health and Human Services estimates that up to
133 million nonelderly Americans may have a preexisting condition.\21\
States applying for a waiver would only be asked to explain how they
intend to maintain access for people with pre-existing conditions; they
would not need to submit any proof that their plan would accomplish
that. Furthermore, this bill also ends the requirement that insurers
cover essential health benefits including hospitalization, maternity
care, and prescription drugs.
---------------------------------------------------------------------------
\21\ Office of the Assistant Secretary for Planning and Evaluation,
``Health Insurance Coverage for Americans with Pre-Existing Conditions:
The Impact of the Affordable Care Act,'' U.S. Department of Health and
Human Services, Washington, DC, 2017.
---------------------------------------------------------------------------
Strengthen Existing Law via Bipartisan Solutions
Congress has the power and responsibility to prioritize the health and
economic security of the American people. I urge you to reject efforts
to strip health care away from those who need it most and instead focus
on taking bipartisan legislative action to reduce uncertainty in the
health insurance marketplace, hold down premiums, and bolster access to
health coverage for more Americans. While the opportunity to improve
the law for the coming year may slip past amid efforts to repeal, work
must be done to strengthen the law in the future. An important starting
point would be to continue work on bipartisan legislation to stabilize
the marketplace that prioritizes the following:
Make the cost-sharing reduction (CSR) payments permanent.
Congress should create a permanent funding stream for CSR payments.
Sixty percent of people with marketplace coverage use CSR payments to
significantly reduce their out-of-pocket health care costs. The
Congressional Budget Office estimates that terminating these payments
would cause benchmark silver plan premiums to increase by an average of
20% and cause 1 million people to lose coverage.
Reinstate and fund the ACA's reinsurance program. Congress
should reinstate and make permanent the reinsurance program to
facilitate increased insurer participation in the marketplace and lower
costs. When it was funded, the ACA's reinsurance program resulted in
lower premiums for consumers. In 2014, the reinsurance program reduced
premiums by 10-14%. Similar savings would help more Americans attain
coverage this open enrollment period.
Prioritize 2018 Latino open enrollment outreach and enrollment
efforts. Congress should appropriate funds and instruct the Department
of Health and Human Services (HHS) to provide enrollment resources and
assistance for all consumers. Congress should also direct HHS to
prioritize communities of color, those with limited English proficiency
(LEP), immigrant and mixed-status families, as well as the LGBTQ
community. These communities historically have had lower coverage rates
and are more likely to be new to our health care system than other
consumers. Our work with Affiliates over four open enrollment periods
demonstrates that in-person, in-language, and culturally competent
consumer outreach and assistance is the most effective way to engage
the Latino community, including LEP and immigrant families. These
resources are critical this year, given the compressed open enrollment
period and the uncertainty surrounding the administration's enforcement
of the ACA.
Conclusion
While the ACA is not perfect, the historic impact of the law cannot be
denied. It has proven to be successful in expanding coverage, improving
health outcomes, and increasing financial security to 20 million
American people. Despite that, this law is under attack again. With
each proposal purporting to strengthen the ACA, the stakes for the
American people are raised and it becomes clearer that positioning
people and families for better health and greater economic security is
not a priority for this Congress. We strongly oppose any plan--
including the Graham-Cassidy bill--that undermines tens of millions of
Americans who have finally been able to obtain quality, affordable
health insurance and that asks the sickest and poorest among us to bear
the brunt of health care costs. These proposals are just cruel. Every
senator who is considering voting for the Graham-Cassidy bill must
realize they are voting to jeopardize the lives and financial stability
of working families back home. You can, and must, do better. Any
national health reform proposal should focus on giving more people, not
fewer, the opportunity for quality, affordable, and accessible health
care. The health and economic security of our country demand it and the
American people deserve no less.
______
Letter Submitted by Laura Wallace
U.S. Senate
Committee on Finance
Dirksen Senate Office Building
Washington, DC 20510-6200
Re: Statement for the record for Graham-Cassidy bill hearing, September
25, 2017
September 22, 2017
Dear Senators:
I am concerned that the Graham-Cassidy bill, if passed, would imperil
access to healthcare for millions of Americans, including myself and my
family. I am particularly concerned about how the bill would affect
premium prices for people with pre-existing conditions. I urge the
Senate to reject any bill that could lead to price discrimination based
on pre-existing conditions.
Before the Affordable Care Act became law, my family struggled to
qualify for comprehensive coverage on the private individual market due
to pre-existing conditions. Once the Affordable Care Act became law, I
was able to purchase a comprehensive plan on the private individual
market. I do not receive a subsidy; I pay the full cost of the premium.
It's not cheap, but before the Affordable Care Act, this type of
comprehensive coverage wasn't available to me on the private individual
market at all; the premiums for what was available were astronomical
because people with pre-existing conditions were charged more.
I am very concerned that if Graham-Cassidy passes, comprehensive
coverage will become either unavailable or unaffordable for me. Graham-
Cassidy would let states decide whether or not they keep various rules
that are currently required at the federal level under the Affordable
Care Act, such those that prevent insurance companies from charging
more for pre-existing conditions, implementing lifetime caps on
coverage, or offering non-comprehensive plans that don't cover
essential health benefits. If my state did not keep those requirements,
my premium would likely go up substantially because of pre-existing
conditions--and any plan might no longer offer such comprehensive
coverage.
I am also concerned that premiums are likely to go up in general if the
individual mandate is repealed, because that would change the risk
pool.
Please reject any bill, including Graham-Cassidy, that could allow
insurers to charge more for pre-existing conditions, implement lifetime
or annual caps, or charge extra for things that are currently
considered essential health benefits (such as prenatal and maternity
care, checkups, lab tests, prescription medication, substance abuse
treatment, etc).
Best regards,
Laura Wallace
CC: Senator Dianne Feinstein, Senator Kamala Harris
______
Wisconsin Board for People With Developmental Disabilities
September 22, 2017
Re: Hearing to consider the Graham-Cassidy-Heller-Johnson proposal,
September 25, 2017
U.S. Senate
Committee on Finance,
Dirksen Senate Office Bldg.
Washington, DC 20510-6200
Dear Chairman Hatch and members of the Senate Finance Committee:
The Wisconsin Board for People with Developmental Disabilities (BPDD)
is charged under the federal Developmental Disabilities Assistance and
Bill of Rights Act (DD Act) with advocacy, capacity building, and
systems change to improve self-determination, independence,
productivity, and integration and inclusion in all facets of community
life for people with developmental disabilities.
We agree with the 75 national disability groups opposed to the Graham-
Cassidy-Heller-Johnson (GCHJ) bill that this legislation puts people
with disabilities at risk and actively undermines the improvements the
DD Act is working to achieve for people with Intellectual and
Developmental Disabilities (I/DD) and their families. Many provisions
within the bill will disproportionately harm people with disabilities,
and threaten Wisconsin's innovative, cost-effective Medicaid programs
that have successfully reduced costs and kept people out of expensive
institutions.
The Graham-Cassidy-Heller-Johnson bill (GCHJ) contains the same ideas
as previous ACA repeal bills including cuts and per capita caps to
Medicaid, weakening of consumer protections, and no controls on rising
health care, prescription, and other increasing costs--and would have
the same negative effects on people with disabilities, people with pre-
existing conditions, and their families.
BPDD hears from Wisconsin people with disabilities and their families
across the state. Their opposition to this bill has been universal.
Medicaid Critical to Wisconsin People With Disabilities and Their
Families
Medicaid pays for the Forward HealthCard and almost 20 Wisconsin
programs--including Family Care, IRIS, Children's Long Term Support,
BadgerCare, intensive autism services, etc.--that help older adults,
people with disabilities, families with children, and low income
working adults.
Fifty percent of people with disabilities in Wisconsin rely on
Medicaid, and people with I/DD participate in all Wisconsin's 20 state
Medicaid programs to stay healthy, become employed, and remain in their
homes.
Medicaid provides essential therapies, equipment, special education
services, and equipment from physical therapists to feeding tubes, and
many other services critical to people with disabilities. Medicaid
funded supports and services often makes the difference between
caregivers being able to keep their jobs or leaving the workforce--
jeopardizing their own financial futures--to care for family members.
Per Capita Caps Threaten Services, Increase Risk for Expensive
Institutionalization
People with disabilities will be disproportionally harmed by Medicaid
cuts and per capita caps. Care for people with disabilities makes up a
significant part of state Medicaid budgets due to their long-term care
needs.
Reduced Federal Funding Threatens Wisconsin Investment and Flexibility
The block grants and per capita caps included in the GCHJ bill do not
provide states with additional flexibility. Current Medicaid law
provides states with tremendous flexibility through waivers to custom
design their state's Medicaid programs. In fact, no two state Medicaid
programs operate the same way, a testament to the Medicaid innovation
and experimentation states have undertaken the past 52 years.
Wisconsin state government has made extensive use of federal waivers
(e.g., BadgerCare Plus, Family Care, Partnership, SeniorCare, IRIS, and
Children's Long-Term Support etc.) to shape and design programs to
specifically meet the health and long-term care needs of the people of
Wisconsin. Because Wisconsin has been able to leverage these
flexibilities, it is the only state in the nation that has eliminated
waiting lists for adults, according to the Kaiser Family Foundation,
and a proposal to do the same for children has been included in this
state budget. Waitlists for long-term care services have ended while
also cutting Medicaid costs by hundreds of millions of dollars and
keeping administrative costs constrained at 2%.
The GCHJ bill will force states to make large and continued cuts to
Medicaid each state budget cycle as the federal funding contribution
continues to decline and costs continue to rise. The Medicaid block
grant and per capita caps proposed in the bill will result in
dramatically reduced funding for Wisconsin, and will force the state to
reduce services, cut optional services, restrict eligibility, and
increase waiting lists.
Early analysis projects Wisconsin may not lose funding immediately, but
projections show a $562M loss of federal funds for Wisconsin's 20
Medicaid programs and ForwardHealth card by 2026. By 2027 Wisconsin
stands to lose $3 billion in federal Medicaid funds. Per capita caps
continue to deepen cuts over time (Avalere predicts $29B reduction to
traditional Wisconsin Medicaid by 2036).
Per Capita Caps and Funding Reductions Put People With Disabilities at
Risk for Institutionalization
Federal Medicaid law currently mandates states to pay for high-cost
institutional facilities (such as nursing homes, and state centers for
the developmentally disabled if states have chosen not to close them).
Wisconsin has dramatically reduced Medicaid costs by keeping people in
the community, progress that this bill threatens to reverse. The home
and community based services (HCBS) on which people with disabilities
rely to live and participate in their communities are especially at
risk because they are optional and could be completely eliminated.
Wisconsin has valued and invested in home and community based (HCBS)
services as a mechanism to maximize people's independence and lower
overall Medicaid spending by keeping people out of expensive
institutions. For more than 20 years, Wisconsin has been expanding the
Medicaid funded long-term care programs Family Care and IRIS; these
programs have dramatically reduced high-cost institutional spending and
kept people in their homes, jobs, and communities.
Since 2002, Family Care and IRIS have reduced overall spending on
Medicaid long term care by 10%, reduced the amount of long term care
Medicaid dollars spent on institutions by 50%, and decreased the number
of people in nursing homes paid for by Medicaid by 35%. Seventy percent
of Wisconsin's long-term care enrollees live in a home or community-
based setting, which are typically 30-40% less expensive than
institutional care. Wisconsin is poised to become one of the only
states in the nation to have no waiting lists for kids and adults
needing home and community based supports.
Per capita caps and the funding reductions that go with them could take
Wisconsin backwards 25 years to the days where people waited years (and
sometimes died waiting) for needed supports or could force people back
into more expensive institutions because they can no longer wait for
home-based supports.
Uncertainty for People With Disabilities With Pre-Existing Conditions
Most people with disabilities have one or more care needs that could be
considered a pre-existing condition. Prior to the ACA, many people with
disabilities faced discrimination, high premium, coverage limits, and
challenges to accessing care from insurers.
The GCHJ bill allows states to choose not to cover Essential Health
Benefits, effectively ending pre existing conditions protections.
States could roll back the 10 essential health benefits (including
hospitalization, prescription drugs, habilitative and rehabilitative
services etc.) currently required to be a part of all insurance plans,
and to permit insurers to charge higher premiums to people with pre-
existing conditions, which means insurers could once again discriminate
based against people based on their medical history. The bill does not
define what ``adequate and affordable'' care means. Without these
protections, experts warn that coverage could become unattainable and/
or unaffordable for many.
The inclusion of high risk pools will provide little protection for
people with pre-
existing conditions. Experts on both sides of the aisle have clearly
warned that high risk pools lead to higher costs, fewer benefits and
waiting lists rationing care for those with pre-existing conditions.
BPPD strongly opposes the GCHJ bill because of these negative impacts
on people with disabilities and urges Congress to work with the
disability community on any changes to both the Affordable Care Act and
existing Medicaid programs.
Sincerely,
Beth Swedeen
Executive Director
______
Wisconsin Family Ties
16 N. Carroll St., Suite 230
Madison, WI 53703
608-267-6800 or 800-422-7145
https://www.wifamilyties.org/
Wisconsin Family Ties is a statewide, parent-run non-profit
organization serving families in that include children and youth with
social, emotional, behavioral or mental health challenges. We are
writing to urge you to oppose the Graham-
Cassidy-Heller-Johnson proposal, which represents a grave threat to the
Medicaid funding upon which so many Wisconsin children and youth with
mental health challenges and their families rely.
According to national estimates, about one in five children have a
diagnosable mental health issue, and the prevalence of childhood severe
emotional disturbance approaches one in 10. According to a 2011 report
from the Kaiser Family Foundation, Medicaid is the single largest
funder of behavioral health treatment nationwide; Kaiser also reports
that in Wisconsin, one in three children is covered by Medicaid/CHIP.
Medicaid is absolutely crucial to the mental health and well-being of
Wisconsin's children and their families.
By instituting per-capita caps on federal Medicaid funding, the Graham-
Cassidy-Heller-Johnson proposal would be devastating to children and
adults with disabilities. The cuts would threaten numerous areas in
which Medicaid programs support children's mental health in Wisconsin,
jeopardizing our state's efforts to make a better future for our
children and youth. The following elements of Medicaid are of
particular concern:
EPSDT (Early Periodic Screening, Diagnosis, and Treatment)
The Medicaid EPSDT benefit, known in Wisconsin as HealthCheck, is the
child health component of Medicaid that allows children and youth to
access comprehensive and preventive health and behavioral health care.
Behavioral health treatment for autism and serious emotional
disturbance falls under the EPSDT benefit. Capping Medicaid will make
it virtually inevitable that states will be unable to maintain the
comprehensive nature of EPSDT, putting the children and youth who need
behavioral therapies at risk.
School Based Services
Medicaid is a critical funding stream for school districts to increase
the number of students who receive mental health services. In
Wisconsin, schools and districts have increasingly sought ways to
partner with community-based mental health providers. The 2017-2019
Wisconsin state budget, which will soon be signed by Governor Scott
Walker, includes grants for comprehensive integration of school/
community mental health partnerships, but the effort will be severely
compromised if the Medicaid funding mechanism for the clinical
therapies is undermined by the Graham-Cassidy-Heller-Johnson proposal.
Children's Long Term Support (CLTS)
Wisconsin has made innovative use of existing flexibilities via the
Children's Long Term Support waiver, covering children and youth with
severe emotional disturbances as well as with physical and
developmental disabilities. The supports provided through this program
help keep children where they belong--in their homes with their
families. Recent research has indicated that parents in families
receiving long-term support services are also more likely to remain
employed, contributing not only to the economy but to their own mental
well-being. The 2017-2019 Wisconsin state budget includes eliminating
the CLTS waiver waiting list, which has grown to 2,200 children (around
a quarter of whom qualify with severe emotional disturbance). Under the
Graham-Cassidy-Heller-Johnson proposal, per capita caps threaten once
again to leave families waiting for assistance that they desperately
need.
Comprehensive Community Services
Finally, the Medicaid caps would also threaten the Medicaid-funded
Comprehensive Community Services (CCS) program, a cornerstone of recent
Wisconsin initiatives to improve mental health care for children and
adults in our state. CCS serves individuals of all ages, including
children and youth, who need ongoing services for mental illness or
substance use disorders. A team of service providers works with each
individual based on that person's individual needs and goals. The CCS
program helps children and youth be more successful at home, at school,
and in the community. The Graham-Cassidy-Heller-Johnson proposal would
set this program, too, at risk.
At a time when so many of Wisconsin's children and youth, and their
families, are facing mental health challenges of crisis-level
proportions, we should not even be considering inflicting such
structural damage on the Medicaid system that supports them. Wisconsin
Family Ties urges the Senate Committee on Finance to reject the Graham-
Cassidy-Heller-Johnson proposal and focus instead on transparent, bi-
partisan negotiations toward strengthening the Affordable Care Act.
Thank you for the opportunity to submit this testimony. Please do not
hesitate to contact me for further information: [email protected]
or by phone at (608) 261-0532.
Joanne Juhnke
Policy Director
______
Letter Submitted by Deanna Wurzbach
September 20, 2017
U.S. Senate
Committee on Finance
Dirksen Senate Office Building
Washington, DC 20510-6200
Re: Graham-Cassidy-Heller-Johnson bill
Dear Committee:
I am writing to tell you about how this bill will adversely affect the
life of my daughter and that of so many others who rely on Medicaid.
My daughter just turned 44 yesterday and ever since the age of 21, she
has been able to hold a part-time job, volunteer in the community and
have the health and pharmaceutical services she needs. She has epilepsy
and brain damage so she is functioning around the age of six
cognitively and has developed a lot of life skills thanks to her
support system. She has job coaches to help her complete her job
cleaning a church successfully and with volunteering at a local
hospital and at a nursing home as well. If this bill comes to fruition,
she will not be able to live as productive a life nor will she be able
to live at home with us as she has done all her life. The loss of all
of these things would result in chaos and heartache in her life. She is
very proud of her abilities, and we are as well. I find it disgraceful
that the most vulnerable of our population is the faction to suffer so
that others can enjoy wealth and power.
I am equally upset that this bill will affect so many others so
adversely. Healthcare and living a life of dignity is a human right not
a luxury or the whim of those in power.
Sincerely,
Deanna Wurzbach
______
Letter Submitted by Miles J. Zaremski, Esq.
September 25, 2017
U.S. Senate
Committee on Finance
Dirksen Senate Office Building
Washington, DC 20510-6200
Re: Statement for the September 25, 2017 hearing on H.R. 1628, as
revised,
a/k/a/ Graham-Cassidy health care bill
Dear Committee Members:
I submit this letter in a non-representative capacity for inclusion in
the official committee record as part of its September 25, 2017 hearing
on the Graham-Cassidy health care bill, H.R. 1628, revised as of
September 24, 2017. I also realize that it will probably not reach the
record before the Senate votes by September 30th, but I consider its
contents important enough to be made part of the official record.
First, and painting with an extremely broad brush, I am a health care
attorney of some 44 years now, with a substantial portion of that time
involved in health care policy, extending back to when the HCQIA
(Health Care Quality Improvement Act) was being developed in the 1980s
and, most recently, being called upon to advise Members of Congress as
the Affordable Care was being crafted in 2009/2010. I have also written
and spoken extensively, nationally as well as on the international
stage, on areas affecting the nation's health care and health care law.
This has included law faculty positions and as an invited speaker at
the University of Chicago, Case Western Reserve, Stetson Law School
(professor, adjunct), and as far away as the Macquarie School of Law in
Sydney, Australia. I have, as well, been the longest serving chair (5
years) of the American Bar Association's Standing Committee on Medical
Professional Liability, and the first non MD-JD president of the
American College of Legal Medicine.
My remarks follow viewing a substantial portion of the committee's
hearing this afternoon on C-SPAN 2.
Besides everything that has been said pro and con on Graham-Cassidy,
one viewpoint that has not been clearly articulated is that this
proposed legislation, if passed, will be a denial of equal protection
for all Americans.
The core of H.R. 1628, as revised, is to give health care back to each
state to administer for its own residents, with the assistance of
government block grants. In so doing, each state will have the
discretion to divvy up those funds as each state's budget allows,
including allowing for more leniency in granting waivers to insurers
for what medical conditions will be covered by them and to what
financial extent such conditions will be paid by them. This certainly
impacts all those with pre-
existing conditions. But what has not been clearly stated is that every
American, generally speaking, is the same physiologically as is the
illness or disease that afflicts each such individual, regardless of
the state, or U.S. commonwealth or territory in which he or she
resides. So, if any one of us contracts a cancer, a pneumonia,
undergoes a joint replacement, or even for females, becomes pregnant,
depending upon where we live, we might obtain better, or worse, health
care through insurance than someone in a neighboring state or across
the country is able to acquire through a state-administered program
under Graham-Cassidy. This, in other words, would be a denial of equal
protection for the same human being that has contracted the same
disease or medical condition. The ACA, while imperfect and requiring a
bipartisan fix for its shortcomings, at least provides uniformity in
mandated health care insurance protections across state lines for all
Americans.
As well, the ``sweeteners'' now being offered to states like Alaska,
Maine, Arizona, and Kentucky (no doubt to attract their senators' votes
on the bill), effectively will provide more benefits to residents in
those states than residents of every other state. And we cannot forget
Graham-Cassidy's redistribution of Medicaid funds from those states
that accepted the expansion under the ACA to those states that rejected
the expended funds.
These three examples constitute, as if in microcosm, a perspective of
denying equal (health care) protection for the citizens of all states
never really addressed in your hearing today, but is an essential one
to be recorded and made part of your committee's record of today's
hearing.
Thank you for allowing me to put forth the above views.
Sincerely,
Miles J. Zaremski
______
Letter Submitted by Ginger Zarske
U.S. Senate
Committee on Finance
Dirksen Senate Office Bldg.
Washington, DC 20510-6200
Re: Hearing to consider the Graham-Cassidy-Heller-Johnson proposal,
September 25, 2017
Senator Hatch and members of the Senate Finance Committee:
I am writing to give my perspectives on the Graham-Cassidy-Heller-
Johnson bill.
First, let me say that you are being churlish and childish in your
commitment to repeal the ACA. President Obama knew it wasn't perfect.
He worked hard to appease everyone, including the Health Care industry,
and he always said that any improvements would be welcomed. You should
be working to negotiate with the Health Care industry and the states to
create a better, more robust plan. Instead, you are systematically
breaking it up and creating nothing but chaos.
It is your fault that insurance carriers are pulling out of states. It
is your fault that some states refuse to expand Medicaid so that low
income families and children can have a decent shot at a life, and it
will be your fault when thousands of people die because they didn't
have adequate health care.
I hope you can't sleep.
Sincerely,
Ginger Zarske
______
Letter Submitted by Miriam and Neil Zusman
U.S. Senate
Committee on Finance
Dirksen Senate Office Bldg.
Washington, DC 20510-6200
Dear Members of the Senate Finance Committee,
Despite claims to the contrary, the proposed amendment known as the the
Graham-Cassidy-Heller-Johnson proposal, S. Amdt. 1030 to H.R. 1628, The
American Health Care Act of 2017, scheduled for the Senate Committee on
Finance meeting September 25th, is a plan that the Republicans are
presenting as just another Patient Protection and Affordable Care Act
(2010) repeal bill that would have the same devastating effects as the
previous repeal bills they tried to get passed, causing at least 15
million people to become uninsured and driving up premiums by 20%!
Eleven governors, including five Republicans and a pivotal Alaskan
independent, as well as the Executive Directors of the American
Association of Retired Persons and the Executive Director of the
American Public Health Association have urged the Senate this past
Tuesday to reject this last-ditch push to dismantle the Patient
Protection and Affordable Care Act (2010).
The plan would completely eliminate the ACA's expansion of Medicaid,
which has extended coverage to 11 million people: low income families
and people with disabilities and children.
It would also completely eliminate the ACA's marketplace subsidies,
which currently help almost 9 million people afford coverage.
It would provide $239 billion less in federal support for Medicaid
coverage between 2020 and 2026, and END completely after 2026. New York
State could lose more than $33 billion by 2027 under the Graham-Cassidy
amendment.
On top of these cuts, the plan would also cap and cut Medicaid for
seniors, people with disabilities, and families with children, cutting
funding outside expansion by about $175 billion between 2020 and 2026.
I believe in quality, affordable healthcare for ALL Americans! I
believe that health care ought to be an American right. A human right
to health means that everyone has the right to the highest attainable
standard of physical and mental health, which includes access to all
medical services, sanitation, adequate food, decent housing, healthy
working conditions, and a clean environment. Please warrant that the
people you represent will have the ability to be productive and healthy
citizens, regardless of their current income, by having affordable
high-quality health care.
Respectfully,
Miriam and Neil Zusman