It is not a bill yet, but the most recent proposal for repeal and replacement of the ACA has many of the same dangerous provisions as the original Graham-Cassidy bill.
Although it is unlikely to be enacted as written, the President’s budget provides an important blueprint of the administration’s priorities for the year. See below for resources on the Trump Administration’s 2019 Budget.
- Explainer from Vox summarizing the proposed budget and what it means here.
- Report from the Center on Budget and Policy Priorities on the proposed budget’s effect on health care here.
Two-Year Congressional Budget
- Blog from The Commonwealth Fund on what the two-year deal got right on health care and what it missed here.
- Article from Vox on the 10-year CHIP re-authorization here.
- Politico article on the two-year budget deal and next steps here.
Federal Budget and Taxes
- Politico article on the addition of the repeal of the individual mandate to the Senate tax bill here.
- Congressional Budget Office (CBO) updated their estimate on the costs and implications of repealing the individual mandate. Available here.
- Center on Budget and Policy Priorities Explainer on how the current budget and tax plans could hurt health care here.
- The Washington Post explains statutory “PAYGO” and how the tax bill could affect Medicare and other programs here and here.
- Check out our blog post on the proposal here.
- Sarah Kliff of Vox describes what the bill does here. Senators Cassidy and Graham are proposing to eliminate the subsidies that help people buy private insurance and end the Medicaid expansion that allows low-income childless adults enroll in Medicaid. The bill is especially written to target states like New York that have more comprehensive Medicaid programs for cuts.
- The Center for Budget and Policy Priorities estimates that the bill would cut federal health funding for New Yorkers by over $18 billion.
- Families USA describes the harmful effects of block grants and eliminating the Essential Health Benefits here.
Non-Legislative Tools Being Used to Weaken the ACA
- Families USA put out an issue brief explaining what’s in the Market Stabilization rule imposed by HHS in April, and making recommendations about how states can protect consumers. The final rule is available here. HCFANY’s comments on the rule are available here.
- New York’s Attorney General joined 14 others to defend cost-sharing reductions. In their argument that states have an interest in defending the CSRs in court even if the Administration will not, AGs laid out some of the impacts a failure to pay CSRs would have on the states.
- Kaiser Family Foundation found that eliminating the ACA’s cost-sharing reductions would cause premiums to rise and insurers to exit the market.
Better Care Act
- The Common Wealth Fund has created a Fact Sheet on how the Senate bill would hurt New York.
- Dan Goldberg at Politico New York has listed some of the harmful effects the bill would have on New York, including higher deductibles and premiums, the elimination of the Essential Plan which currently covers almost 700,000 people, and banning lawfully present immigrants from receiving assistance.
- Dylan Matthews at Vox has enumerated the people the Senate bill will hurt and how, including the working poor, seniors, people with disabilities, communities affected by the opioid crisis, people in states like New York that have above average Medicaid spending, pregnant women and new mothers, and people over 60 but under 65.
- The Center on Budget and Policy Priorities has created a running summary of new reports on the bill.
- The Urban Institute estimated what a 60-year-old New Yorker would pay for premiums and deductibles under the ACA versus BCRA. They estimate that a person earning $49,400 (400 percent of the federal poverty level) would pay $16,520, over twice as much as under the ACA.
Statements from New York’s Leaders
- Governor Andrew Cuomo called the bill “inhumane” and said it “hurts middle class New Yorkers, discriminates against women, defunds Planned Parenthood, and turns its back on the most vulnerable Americans.”
Changes to Medicaid
- The Center for Budget and Policy Priorities has shown that the tax cuts the bill gives to the wealthiest 400 families in the US currently provide health insurance to over 700,000 people.
- The Urban Institute has shown how pinning Medicaid spending to the Consumer Price Index instead of medical prices would increase the bill’s Medicaid cuts by $467.4 billion over the House bill.
- The massive Medicaid cuts proposed by the Senate would be especially bad for rural hospitals. Rural hospitals benefited from Medicaid expansion because fewer of their patients were uninsured.
Changes to the ACA
- Jeffrey Young at the Huffington Post describes how the bill would lead to a ‘death spiral’ in the individual market. The bill would repeal the individual mandate, which encourages healthy people to buy insurance and spreads the cost of health care for people who get sick around a bigger group of people. Without incentives to buy insurance, the number of people sharing those costs gets smaller and smaller until insurance becomes unaffordable for almost everyone. New York has experienced this before.
- Jonathan Cohn at the Huffington Post has explained how the bill increases deductibles by forcing people to buy plans with higher cost-sharing in order to qualify for premium assistance.
American Health Care Act (the House bill)
- The Congressional Budget Office released its assessment of the modified version of the AHCA that passed the House in May. CBO found that the bill would cause 23 million American to lose coverage. The bill’s biggest costs come from reducing payroll and investment income taxes for high-income individuals and insurance companies, and its new age-based tax credits. Its biggest spending reductions come from cutting Medicaid and subsidies for people who buy their own insurance. (You can find the score for the original bill here).
- Consumer representatives to the National Association of Insurance Commissioners released a new report on “The Need for Continued Consumer Protections and Stability in State Insurance Markets in a Climate of Federal Uncertainty.”
- The Medicare Rights Center expressed concern over the “secretive and rushed manner” in which the bill was developed, and concern about the negative effects it will have on people with disabilities and the elderly.
- The American Cancer Society’s Cancer Action Network opposes the bill, arguing it shifts costs to low and middle-income patients, reduce the quality of insurance plans, and substantially reduce Medicaid funding.
- The American Hospital Association does not support the bill, arguing that the Medicaid caps will lead to “significant reductions in a program that provides services to our most vulnerable populations” and reminding Congress that progress on our substance abuse crisis is linked to the progress we’ve made on insurance coverage. America’s Essential Hospitals also opposes the bill, arguing that capping Medicaid spending and de-funding the Medicaid expansion to childless adults would force them to reduce services and staff.
- The American Medical Association opposes the bill overall. The organization particularly highlighted the bill’s age-based, instead of income-based, financial assistance; its roll-back of the Medicaid expansion; capped funding for Medicaid; its elimination of the Public Health and Prevention Fund; and its de-funding of Planned Parenthood.
- The AARP has come out against the idea of allowing insurers to charge older people five times more than younger people in a video. The ACA allows insurers to charge older people three times more.
- Initial estimates of coverage losses range from 6 to 10 million newly uninsured to 20 million. Standard & Poor’s estimates 6 to 10 million, assuming that in wealthier states like New York, tax payers will begin paying more to cover the federal cuts.
- The Institute for Child, Youth and Family Policy at Brandeis University estimated that five million children would lose federal Medicaid eligibility if the ACA is repealed, and the harm would disproportionately fall on children of color.
Capping and Cutting Medicaid
- The Commonwealth Fund examined the history of proposals to change Medicaid into a block-grant program or to fund it based on per-capita caps. They argue that both would “divorce funding considerations from the real-life needs that have informed federal and state Medicaid policy for half a century.”
- Georgetown’s Center for Children and Families found that 42 percent of kids are covered by Medicaid in New York’s rural areas and small towns.
- The Center for American Progress examined how states might respond to large federal cuts to Medicaid, and found that during other budget crises, states raised taxes and reduced education spending.
Health Savings Accounts
- The Center on Budget and Policy Priorities examined whether health savings accounts are a suitable replacement for the ACA, finding that the accounts “do little or nothing to help the uninsured afford coverage but offer high-income people lucrative tax-sheltering opportunities.”
- The Commonwealth Fund examined the results of the national high-risk pool that existed before the ACA’s pre-existing condition protections, and concludes that the pools are “prohibitively expensive” for both states and consumers while offering “much less than optimal” coverage.
- The Kaiser Family Foundation found that the national high-risk pool and the 35 high-risk pools run by states before the ACA covered only a fraction of the people who could not buy insurance because of their pre-existing condition, typically did not cover services related to the person’s pre-existing condition for some period of time, and charged premiums “substantially in excess of what a typical person would pay in the non-group market.”
Older Resources on the ACA Repeal
July 2017: The Senate released a new bill that will repeal the ACA (the “Obamacare Repeal Reconciliation Act,” or ORRA). The bill is a much more straightforward repeal of the ACA than previous versions. The Congressional Budget Office analyzed the bill and found that it would double premiums, increase the number of people without insurance by 32 million, and leave 3/4ths of the country without any insurance companies to buy from.
June 2017: The Senate released its bill, and it’s even crueler than the House bill. The version that was revised as of June 26 is available here. The Congressional Research Service also released a plain English summary, available here. The Congressional Budget Office report showing that 22 million people would lose insurance if the bill passed is here.
Impact on New York
- The Urban Institute found that the ACA’s success in increasing health insurance coverage reduced the number of New Yorkers with medical debt, from 24 percent to 19 percent.
- A group of health advocates including Health Care for American Now! produced a New York state fact sheet finding that 1.1 million New Yorkers would lose coverage.
- Governor Cuomo provided county-by-county estimates of coverage losses (totaling about 14 percent of the state’s population) and direct budget impacts of a repeal ($3.7 billion).
- The Commonwealth Fund estimates that an ACA repeal will kill around 131,000 jobs in New York.
- Families USA estimated that New York would lose $57 billion over ten years and that 124,000 New Yorkers will lose premium assistance. They also provide estimates of coverage losses and the numbers of New Yorkers benefiting from things like the ban on lifetime limits, guaranteed issue, the closure of Medicare’s “donut hole” and the medical loss ratio.
- The Kaiser Family Foundation estimates that around 25 percent of New Yorkers (over 3 million people) have a pre-existing condition that could exclude them from purchasing plans without the ACA’s protections.
- The New York State of Health provided county-level totals for people who enrolled in Medicaid, Child Health Plus (CHP), the Essential Plan (EP), or Qualified Health Plans (QHPs) during 2017’s open enrollment.
Statements from New York’s Leaders
- Governor Andrew Cuomo asked the House Majority Leader to “do no harm,” and to reject the ACA repeal and any plan to turn Medicaid into a block grant program or cap its funding on a per-capita basis.
- Department of Financial Services Superintendent Maria Vullo argued that repealing the ACA with no replacement would be “disastrous” for our insurance markets and discussed the importance of the individual mandate and tax credits for keeping premiums down. She also argued that allowing insurance sales across state borders would create a ‘race to the bottom’ and “violate a fundamental principle of state sovereignty.”
National Estimates and Commentary
- The Congressional Budget Office estimates that repealing the individual mandate, premium assistance, and the Medicaid expansion would cause premiums to double and 32 million people to become uninsured by 2026. They also estimate that in the first year, half of Americans would live in places with no individual plans available at all and this would increase to 75 percent of Americans by 2026.
- The American Academy of Actuaries sent a letter to Speaker Ryan and Leader Pelosi saying that a repeal without replacement would cause the individual market to deteriorate immediately, even with a delayed implementation, and that taking away the cost-sharing reduction payments to insurers would lead to “solvency challenges.”
- The American Hospital Association estimates that an ACA repeal will result in a loss of $289.5 billion to hospitals if it maintains cuts to disproportionate share payments, and a loss of $165.8 billion if those cuts are reversed. In a letter to President Trump, the AHA said that “losses of this magnitude cannot be sustained and will adversely impact patients’ access to care, decimate hospitals’ and health systems’ ability to provide services, weaken local economies that hospitals help sustain and grow, and result in massive job losses.”
- The Urban Institute estimated that providers would be hit by an additional $84 billion in uncompensated care in 2019 provided to patients who no longer have health insurance, and an additional trillion dollars in uncompensated care over 10 years.
- The American Enterprise Institute argues that the ACA should not be repealed without a comprehensive replacement in place, that “health insurance is a necessity of modern life,” and that “households with low incomes will never be able to pay the premiums for health insurance without government assistance.” They recommend allowing people with ACA-subsidized coverage and people who are newly eligible for Medicaid to keep their existing coverage indefinitely.
- The Office of the Assistant Secretary for Planning and Evaluation (within the Department of Health & Human Services) found that expanding Medicaid to childless adults improved access to primary care and preventive services, helped people with chronic conditions get diagnosed, and reduced the risk of personal bankruptcy.
- The Center on Budget and Policy Priorities estimates that the Medicaid expansion implemented through the ACA provided 11 million Americans with health insurance. They also point out that the expansion helped states save money by eliminating the need for state programs that provided emergency care for people who now get care through Medicaid.
Medicaid Block Grants
- The Center for Budget and Policy Priorities argues that changing Medicaid into a block-grant program would lead to “draconian cuts to eligibility, benefits, and provider payment rates.” They cite Urban Institute data suggesting that between 14 and 21 million people would lose coverage.
Selling Insurance Across State Lines
- The National Association of Insurance Commissioners and the Center for Insurance Policy & Research argued that allowing insurance sales across state lines would “make insurance less available, make insurers less accountable, and prevent regulators from assisting consumers in their states.”