Obamacare is the name most frequently used to refer to President Barack Obama’s signature piece of health care legislation. That’s not the actual name off the health care law, though.  The phrase “Obama-care” was first used by lobbyist Jeanne Schultz Scott in the trade journal Healthcare Financial Management in March 2007.

The name of the law is the Patient Protection and Affordable Care Act. (PPACA).  It is often shortened to Affordable Care Act (ACA).  People also call the health care law Obamacare, and it is also sometimes spelled as ObamaCare.

On March 3, 2016, The New York Times reported that President Obama said that enrollment in health coverage under the Affordable Care Act had reached a new high – 20 million people. That figure includes people who have received private health insurance on the exchanges, those who gained Medicaid coverage under state expansions, and young adults who were able to stay on their parents’ health plans until age 26.

Here is what happened to Obamacare after President Trump took office on January 20, 2017, with a Republican majority in both the U.S. Senate and in the U.S. House of Representatives.

Before I start this timeline of the GOP attempting to destroy Obamacare, I want to go back to The New York Times article (linked above).  The article was talking about a speech given by President Barack Obama in Milwaukee. He said:

Congressional Republicans have tried and failed to repeal Obamacare about 60 times. They have told you what they would replace it with zero times.

If they got their way, 20 million people would have their health insurance taken away from them. Twenty million people!”

As I worked on putting this blog together, I realized that the GOP’s interest in taking away access to affordable health care spanned farther than Obamacare.  They were also making efforts rip away funding for women’s health care, children’s health care, healthcare for people who are LBGT,  and even the health care program for miners who have black lung.

January 20, 2017: The New York Times posted an article titled: “Trump Issues Executive Order Scaling Back Parts of Obamacare”. It was written by Julie Hershfeld Davis and Robert Pear. From the article:

In his first executive order, President Trump on Friday directed government agencies to scale back as many aspects of the Affordable Care Act as possible, moving within hours of being sworn in to fulfill his pledge to eviscerate Barack Obama’s signature health care law.

The one-page order, which Mr. Trump signed in a hastily arranged Oval Office ceremony shortly before departing for the inaugural balls, gave no specifics about which aspects of the law it was targeting. But its broad language gave federal agencies wide latitude to change, delay or waive provisions of the law that they deemed overly costly for insurers, drug makers, doctors, patients or states, suggesting that it could have wide-ranging impact, and essentially allowing the dismantling of the law to begin even before Congress moves to repeal it…

…”In the meantime,” the order said, “pending such repeal, it is imperative for the executive branch to ensure that the law is being efficiently implemented, take all actions consistent with law to minimize the unwarranted economic and regulatory burdens of the act, and prepare to afford the states more flexibility and control to create a more free and open health care market.”…

…Using the phrase “to the maximum extent permitted by law,” the order directs federal agencies to move decisively to implement changes, including granting flexibility that insurers and states had long implored the Obama administration to provide.

It also instructs them to work to create a system that allows the sale of health insurance across state lines, which Republicans have long proposed as the centerpiece of an alternative to the law.

The order does not direct the Department of Health and Human Services to ease any particular aspect of the 2010 law, but it could result in a substantial weakening of one of its central features: the so-called “individual mandate” that requires most Americans to have health insurance or pay a tax penalty…

February 14, 2017: Donald J. Trump @realDonaldTrump tweeted: “Obamacare continues to fail. Humana to pull out in 2018. Will repeal, replace & save healthcare for ALL Americans”.  The tweet included a link to the following article from The Hill.

February 14, 2017: The Hill posted an article titled: “Humana to drop out of ObamaCare at end of 2017”. It was written by Jessie Hellmann. From the article:

Health Insurance company Humana announced Tuesday that it would leave ObamaCare market in 2018.

The insurer said it would offer plans through 2017, but that the market has not stabilized enough to participate next year.

Humana said it was losing money from taking on too many sick people without enough healthy people to balance the pools.

The decision came after Humana scaled back participation and raised premiums, among other changes…

…Humana scaled back its exchange participation to 11 states and 156 counties in 2017, down from 1,351 counties in 19 states the previous year.

The withdrawal will have a big impact in Tennessee, where it is the only exchange insurer in several counties.

Humana is also one of only two insurers in dozens of counties in states like Mississippi and Georgia.

The move comes as other insurers worry about the looming ObamaCare repeal push in Congress…

March 9, 2017: GovTrack provided information about The American Health Care Act of 2017 (AHCA). From the information:

…On March 9, 2017, the text of the AHCA was first made available. It was a comprehensive plan that repealed major parts of the ACA, including the Medicaid expansion and many taxes, but also kept major parts of the ACA intact, such as the exchanges…

GovTrack provided a summary of the AHCA as of March 9:

What would stay the same:

  • The AHCA would keep the ACA’s requirement that dependents can stay “on their parent’s plan until they are 26.”
  • The exchanges (aka marketplaces) run by the federal government and states, which listed individual and small business health insurance plans, would continue under the ACA.
  • The ACHA would also continue to provide subsidies for premiums that are based on income, although the formula would be completely different and the subsidy would likely be much less for young, low-income Americans.
  • The AHCA would keep some Medicaid benefits for those that enroll prior to 2020.
  • The AHCA would keep the restriction that subsidies can’t pay for health insurance that covers abortion.

Changes to the individual mandate: 

The AHCA even includes a penalty for individuals who don’t get coverage, referred to as the “individual mandate” in the ACA. While the ACA imposes a roughly $700 per year penalty for not holding health insurance, the AHCA would instead impose a surcharge of up to 30% the next time you get insurance after a lapse in coverage.

Depending on your premiums and how long you go without insurance, the ACHA’s penalty could be more or less than the ACA’s current penalty. In many cases, it might be about the same.

What would be expanded:

  • Contribution limits to Health Savings Accounts (HSAs) would be increased to encourage their use. With HSAs, you can put aside some of your income for medical expenses, and not pay taxes on it.
  • Under the AHA, federal subsidies for paying premiums could be used to pay for insurance both from and not from the exchanges.

Some parts of the ACA would end:

Medicaid:

  • The ACA expanded Medicaid eligibility in 32 states that opted in to it. The AHCA would reverse the eligibility expansion beginning in 2020 (anyone enrolled by then would remain enrolled), and it would reduce federal support for Medicaid with caps on coverage.
  • The ACA expanded required benefits under Medicaid, such as mental health and addiction services, which would no longer be required.

Covered through an employer:

  • Fines would be eliminated for large employers that don’t provide health plans.
  • Small business tax credits would end in 2020.

Covered through an individual plan:

  • The ACA limited what health insurance providers could charge in premiums. Under the AHCA, those limits would be adjusted so that younger people might see lower premiums and older people much higher premiums.
  • The ACA’s complex cost-sharing provisions that lowered costs for some low-income Americans would be eliminated.
  • The ACA’s awkward bronze/silver/platinum level would go away.

Other changes:

  • A long list of taxes created by the ACA to pay for its subsidies would be eliminated, but some new taxes will be added, such as a new tax on the value of health insurance provided by an employer.
  • Parts of last year’s last-minute bipartisan 21st Century Cures Act would be defunded.

“Defunding” Planned Parenthood:

  • The AHCA would prohibit federal funding from going to Planned Parenthood, mostly through Medicaid, for one year.
  • This would pause federal reimbursements for Planned Parenthood’s reproductive health, maternal health, and child health services — but not its abortion services because federal funs are already prohibited from being used for abortion.

Bottom line:

How the AHCA would affect you depends on your income, how you get your health insurance, and what kinds of care you need.

  • For older, low-income Americans with health insurance from the individual market: Premiums could increase by $3,600 for a 55-year-old earning $25,000 a year, and $8,400 for a 64-year-old earning $15,000 a year.
  • For low-income Americans covered by Medicaid, the federal cap on support would likely lead to fewer benefits and higher out-of-pocket costs. 5 to 8 million individuals are predicted to lose Medicaid coverage entirely.
  • If you are covered by your employer, your employer would be allowed to stop providing coverage — and that’s made more likely because tax credits and the tax advantage for employer-provided coverage would be eliminated. But experts are split on whether the AHCA will affect employer coverage — and even whether the ACA ever had any effect on employer coverage to begin with.
  • Americans with income around $40,000 – $75,000 who purchase an individual plan may be better off because the ACA’s subsidies for low-income Americans would be spread out to income up to $75,000 (unless premiums go up too). If your income is below that, some of your subsidies are now going to go to other people with higher income.
  • If you have an income of $200,000 or more, or investment income, you can expect your tax bill to go down — those making $1 million or more can expect around $50,000 less in taxes each year.

March 11, 2017: Donald J. Trump @realDonaldTrump tweeted: “We are making great progress with healthcare. ObamaCare is imploding and will only get worse. Republicans coming together to get job done!”

March 13, 2017: Donald J. Trump @realDonaldTrump tweeted: “ObamaCare is imploding. It is a disaster and 2017 will be the worse year yet, by far! Republicans will come together and save the day.”

March 24, 2017: Donald J, Trump @realDonaldTrump tweeted: “The irony is that the Freedom Caucus, which is very pro life and against Planned Parenthood, allows P.P. to continue if they stop this plan!”

March 25, 2017: Donald J. Trump @realDonaldTrump tweeted: “ObamaCare will explode and we will all get together and piece together a great healthcare plan for THE PEOPLE. Do not worry!”

March 26, 2017: Donald J. Trump @realDonaldTrump tweeted: “Democrats are smiling in D.C. that the Freedom Caucus, with the help of Club For Growth and Heritage, have saved Planned Parenthood and Ocare!”

March 26, 2017: The Hill posted an article titled: Trump: Conservative lawmakers, groups ‘saved’ Planned Parenthood, Obamacare”. It was written by Kyle Balluck and Rebecca Savransky. From the article:

President Trump early Sunday said the conservative House Freedom Caucus, along with the Club for Growth and Heritage Action for America “saved” Planned Parenthood and Obamacare.

“Democrats are smiling in D.C. that the Freedom Caucus, with the help of Club for Growth and Heritage, have saved Planned Parenthood & Ocare!” Trump tweeted…

…His comments come after Speaker Paul Ryan (R-Wis.) on Friday pulled the GOP healthcare bill amid dwindling support among Republicans. The move, which marked the president’s first legislative defeat, comes after seven years of rhetoric from Republicans who campaigned on repealing and replacing former President Barack Obama’s signature healthcare legislation.

After the bill was pulled, the president blamed Democrats for not backing the GOP healthcare proposal and signaled he would move on to other legislative priorities.

The president met with members of the Freedom Caucus last week in his push to whip up votes for the GOP healthcare bill. But House conservatives wanted the bill to go further in taking apart ObamaCare and were hoping for specific policy concessions from Trump.

Before the bill was pulled, most Freedom Caucus members indicated they wouldn’t back the bill, as did a number of centrist Republicans…

April 2, 2017: Donald J. Trump @realDonaldTrump tweeted: “Anybody (especially Fake News media) who thinks that Repeal & Replace of ObamaCare is dead does not know the love and strength in the R Party!”

April 2, 2017: Donald J. Trump @realDonaldTrump tweeted: “Talks on Repealing and Replacing ObamaCare are, and have been, going on, and will continue until such time as a deal is hopefully struck.”

April 13, 2017: The New York Times posted an article titled: “Trump Signs Law Taking Aim at Planned Parenthood Funding”. It was written by Julie Hirschfeld Davis. From the article:

President Trump signed legislation on Thursday aimed at cutting off federal funding to Planned Parenthood and other groups that perform abortions, a move cheered by conservatives who have clamored to impose curbs on reproductive rights.

The measure nullifies a rule completed in the last days of the Obama administration that effectively barred state and local governments from withholding federal funding for family planning services related to contraception, sexually transmitted infections, fertility pregnancy care, and cervical cancer screening from qualified health providers – regardless of whether or not they also preform abortions. The new measure cleared Congress last month with Vice President Mike Pence casting the tie breaking vote in the Senate.

The previous Department of Health and Human Services regulation, which took effect two day before Mr. Trump’s inauguration, said that states and localities could not withhold money from a provider for any reason other than an inability to provide family planning services.

Mr. Trump has shown ambivalence about Planned Parenthood, voicing support for its health-related services other than abortion, and his daughter Ivanka has urged him to tread carefully on the issue, concerned about the possible political repercussions of the Republican effort to defund the organization altogether. As a middle ground, Mr. Trump has proposed preserving federal funding for Planned Parenthood if it stops providing abortion services.

The organization has said it will never accept such a deal. Ad federal law already prohibits government funding for abortion, except in cases of rape or incest, or to save a woman’s life.

Regardless of his misgivings about the effort, Mr. Trump appeared ready to accept congressional Republicans’ idea of using a broad health care overhaul to strip all federal money from Planned Parenthood. When the Freedom Caucus, a conservative faction of House Republicans, refused to support legislation to repeal the Affordable Care Act last month, Mr. Trump took to Twitter to denounce the group, saying it had “saved Planned Parenthood.”…

…The rule reversed on Thursday was a response by the Obama administration to moves by more than a dozen Republican-controlled states in recent years to defund Planned Parenthood and other abortion providers. They did so by blocking clinics from receiving Title X money – named for the 1970 law that created the federal family planning program – as well as Medicaid reimbursements.

State courts have ruled against such restrictions for Medicaid reimbursements, but since Title X money is distributed through grants to states, they have the power to set criteria for recipients…

April 30, 2017: Donald J. Trump @realDonaldTrump tweeted: “You can’t compare anything to ObamaCare because ObamaCare is dead. Dems want billions to go to Insurance Companies to bail out donors…New”

May 4, 2017: Senator Lindsey Graham @LindesyGrahamSC tweeted: “A bill – – finalized yesterday, has not been scored, amendments not allowed, and 3 hours final debate – – should be viewed with caution.”

May 4, 2017: GovTrack posted information about The American Health Care Act of 2017 (AHCA) – and updated that information periodically.  From the information:

  • The American Health Care Act of 2017 (AHCA) was a leading proposal in the first half of 2017 by House Republicans to “repeal and replace” the Affordable Care Act (aka Obamacare) and “defund” Planned Parenthood. It was also the vehicle for passage of the Senate Republicans’ leading proposals.
  • The bill was brought to the House and Senate floors under the rules of the budget reconciliation process, by which one bill each year is immune to a Senate filibuster so long as it meets certain requirements related to the budget. By being immune to a filibuster, only 51 votes were needed in the Senate rather than 60. But during Senate preceding the bill was nevertheless ruled out of order for having provisions that were not related to the budget, forcing several votes with the 60-vote threshold.

GovTrack also provided a summary of the AHCA as passed by the House of Representatives on May 4, 2017:

  • States may opt-out of providing the ACA’s essential health benefits (This requirement was already dropped in the bill for Medicaid but not for the individual market).
  • States may opt-out of requiring premiums to be the same for all people of the same age, so while individuals with pre-existing conditions must be offered health insurance, there is no limit on the cost of that insurance. A new $8 billion fund would help lower premiums for these individuals.
  • States may opt-out of limiting premium differences based on age.
  • There would be a $15 billion fund for risk sharing to help states lower premiums.

May 4, 2017: The U.S. House of Representatives voted on the American Health Care Act (AHCA). The vote was 217 YEAS to 213 NAYS.  This means that the AHCA bill passed the House of Representatives.

Most of the Republican Representatives voted YEA. Some Republican Representatives voted NAY:

  • Andy Biggs (Arizona District 5)
  • Mike Coffman (Colorado District 6)
  • Barbara Comstock (Virginia District 10)
  • Ryan Costello (Pennsylvania District 6)
  • Charlie Dent (Pennsylvania District 15)
  • Dan Donovan (New York District 11)
  • Brian Fitzpatrick (Pennsylvania District 8)
  • Jamie Herrera Beutler (Washington District 3)
  • Will Hurd (Texas District 23)
  • Walter Jones (North Carolina District 3)
  • David Joyce (Ohio District 14)
  • John Katko (New York District 24)
  • Leonard Lance (New Jersey District 7)
  • Frank A. LoBiondo (New Jersey District 2)
  • Thomas Massie (Kentucky District 4)
  • Pat Meehan (Pennsylvania District 7)
  • Dave Reichert (Washington District 8)
  • Ileana Ros-Lehtinen (Florida District 27)
  • Chris Smith (New Jersey District 4)
  • Mike Turner (Ohio District 10)

All of the Democratic Representatives voted NAY.

May 4, 2017: The New York Times posted an article titled: “House Passes Measure to Repeal and Replace the Affordable Care Act”. It was written by Thomas Kaplan and Robert Pear. From the article:

The House on Thursday narrowly approved legislation to repeal and replace major parts of the Affordable Care Act, as Republicans recovered from their earlier failures and moved a step closer to delivering on their promise to reshape American health care without mandated insurance coverage.

The vote, 217 to 213 held on President Trump’s 105th day in office is a significant step on what could be a long legislative road. Twenty Republicans bolted from their leadership to vote no. But the win keeps alive the party’s dream of unwinding President Barack Obama’s signature domestic achievement.

The House measure faces profound uncertainty in the Senate, where a handful of Republican senators immediately rejected it, signaling that they would start work on a new version of the bill virtually from scratch…

…Even before the vote, some Republican senators had expressed deep reservations about one of the most important provisions of the House bill, which would roll back the expansion of Medicaid under the Affordable Care Act.

But a softening of the House bill, which could help it get through the Senate, would present new problems. For any repeal measure to become law, the House and the Senate would have to agree on the language, a formidable challenge…

…After weeks of negotiations and false starts, Mr. Trump and House Republicans were not about to dwell on the tough road ahead. Passage of the health care bill completed a remarkable act of political resuscitation, six weeks after House leaders failed to muster the votes to pass an earlier version of the measure, a blow to Mr. Trump and Speaker Paul D. Ryan of Wisconsin…

…Trump quickly turned his attention to pressuring the Senate to act, calling the majority leader, Mitch McConnell, Republican of Kentucky, to talk about the way forward for the health plan.

Democrats, who voted unanimously against the bill, vowed to make Republicans pay a political price for pushing such unpopular legislation. As Republicans reached the threshold for passage, Democrats serenaded them with , “Na na na na, na na na na, hey hey hey, goodbye!”…

…The House bill would eliminate tax penalties for people who go without health insurance. It would roll back state-by-state expansions of Medicaid, which covered millions of low-income Americans. And in place of government-subsidized insurance policies offered exclusively on the Affordable Care Act’s marketplaces, the bill would offer tax credits of $2,000 to $4,000 a year, depending on age…

…The nonpartisan Congressional Budget Office said the first version of the bill would trim the federal budget deficits considerably but would also leave 24 million more Americans without health insurance after a decade. Average insurance premiums would be 15 percent to 20 percent higher in 2018 and 2019, but after that, they would be lower than projected under current law…

…Doctors, hospitals and other health care providers joined patient advocacy groups like the American Cancer Society and AARP in opposing the repeal bill…

…The House vote on Thursday occurred before the Congressional Budget Office had released a new analysis of the revised bill with its cost and impact. Democrats angrily questioned how Republicans could vote on a bill that would affect millions of people and a large slice of the American economy without knowing the ramifications…

May 4, 2017: Mother Jones posted an article titled: “Republicans Just Voted to Take Away Health Care From Millions of People”. It was written by Patrick Caldwell. From the article:

Republicans in the House of Representatives narrowly voted to repeal Obamacare Thursday afternoon, approving a bill that would cut Medicaid funding by 25 percent, allow older Americans to be charged higher health premiums, and scrap all federal funding for Planned Parenthood. It would also allow states to permit insurance companies to charge more for people with preexisting conditions and to choose not to provide a range of benefits, including maternity care and mental health care.

The House passed the GOP plan, dubbed the American Health Care Act, by a 217-213 margin, with all but 20 Republicans voting in favor of the law. No Democrats voted for the bill. The bill will now head to the Senate, where a number of Republicans have called for significant changes to the legislation.

When the Congressional Budget Office analyzed an earlier version of the AHCS in March, it found that under the bill, 24 million fewer people would have health insurance than under Obamacare – and that was before Republicans added a provision allowing insurance companies to raise rates on people with preexisting conditions in stats that receive a waiver. But we still don’t know exactly what impact the bill that just passed the House will have; that’s because Republicans rushed through the vote before the CBO could release estimates of how many people would be insured under the new legislation.

The Republican bill is a hodgepodge of policies overturning Obamacare. It includes the most controversial parts of the original Obamacare repeal bill that Republicans pushed for in March. For example, it would replace the current Obamacare assistance for premiums – which guarantee that lower-income families will only have to devote a certain percentage of their income to buying insurance – with a lower subsidy based strictly on age. It also ends Obamacare’s Medicaid expansion and imposes a cap on all Medicaid funding; those provisions will result in the government spending $880 million less on Medicaid over the next decade, lowering annual Medicaid spending by 25 percent in 2026 and covering 14 million fewer people through that program. The bill also replaces Obamacare’s age restrictions: Current law allows insurance companies to charge older Americans a maximum of three times as much as younger people. Trumpcare would bump that ratio up to 5-to-1, raising the rates for older people who don’t yet qualify for Medicare…

May 25, 2017: Mother Jones posted an article titled: “The GOP Health Bill Would Make Zika the Newest Preexisting Condition”. It was written by Rebecca Leber. From the article:

The controversial GOP health care bill that narrowly passed the House of Representatives this month could have devastating consequences for mothers and children infected with Zika, experts say. The mosquito-borne virus is just one on a nearly endless list of preexisting medical conditions – cancer, asthma, pregnancy – for which insurers could potentially charge higher premiums if Republicans get their way.

One of the most popular features of Obamacare is a provision known as “community rating”, which bars insurance from charging more for people with preexisting conditions. This was a common practice before Obamacare was enacted in 2010; stories of sick people being unable to find affordable coverage were one of the main arguments used by the legislation’s supporters. Of course, the public health crisis surrounding Zika – and the birth defects it can cause – wasn’t an issue at the time; no one in the United States had yet contracted the virus. But if the House’s Obamacare repeal bill becomes law, people with Zika could end up paying far more for their health care – and could even end up priced out of insurance entirely.

Multiple health care experts told Mother Jones that the GOP bill would almost certainly mean a host of insurance problems for both pregnant women who have had Zika and infants born with microcephaly, a condition where a child has a smaller brain and other health defects. Zika can cause a host of other birth defects and in rare cases has been linked to Guillian-Barré syndrome, which can cause temporary paralysis in adults. What’s more, the GOP bill cuts funding to the Centers for Disease Control and Prevention, the agency on the front lines of the battle against the disease.

The Republican bill includes an amendment that allows states to opt out of the Obamacare community rating protection. Under the GOP plan, if a person’s health coverage were to lapse longer than 63 days in a state that opts out, that person could be charged a prohibitive cost on the private market. Short lapses in coverage are incredibly common. The Kaiser Family Foundation estimates that 27.4 million non elderly adults had a several-month gap in coverage in 2015. For the 6.3 million of these adults who have preexisting conditions, the costs could be significant. the liberal Center for American Progress estimated that under the GOP bill, people with even mild preexisting conditions would pay thousands more per year – a 40-year-old, for example, would likely be charged an extra $4,340 in premiums if she had asthma, or $17,320 extra if she were pregnant…

May 4, 2017: Wired posted an article titled: “The House Health Plan Makes Your Genes A Preexisting Condition”. It was written by Adam Rogers. From the article:

…The ACA specifically protected against discriminations for preexisting conditions that showed up through genetic tests. You might not be sick yet – in technical terms, the illness has not manifested – but if you, for example, test positive for one of the pathogenic variants (a less X-Manly term than “mutation”) in the BRCA gene that predisposes you to breast cancer, you could still get covered. If the House bill becomes law, that protection vanishes…

…It’s not like nobody saw this debate coming. Even back when sequencing a human genome cost $100 million, policymakers and scientists were trying to figure out how to safely get data from people while simultaneously keeping insurers and employers from using it to screw them. After a decade of debate, the result was the Genetic Information Nondiscrimination Act, a 2008 bill that aimed to protect people’s genetic privacy. GINA wasn’t perfect – it doesn’t extend to long-term care and life insurance for example.

GINA also doesn’t quite define illness. It protects family history and tests of DNA, RNA, proteins, metabolites, and other indicators – a panoply of -omics beyond just genomics. But it doesn’t protect you if you already have symptoms. So then the question is, what counts as a symptom? Is a person only sick when they first start feeling pain? When a doctor prescribes a drug? Or when something changes on a cellular level? “When you don’t have symptoms and you aren’t disabled or have some significant clinical syndrome, does that mean that it’s preexisting? When its encoded in your DNA or other parts of your intrinsic self?” [Eric] Tool [a geneticist at the Scripps Research Institute] asks…

…thans to the ACA becoming law just a couple of years after GINA, nobody ever really had time to find out what GINA will actually protect. “These definitions haven’t been fully tested because they haven’t shown up in court,” [Anya] Prince, [a lawyer and researcher at the Center for Genomics and Society at UNC] says. Just an example: Fiscal 2013 saw 333 employment discrimination complaints based on GINA…and 90,000 based on everything else – mostly the Americans with Disabilities Act. Most people have never even heard of GINA. If Congress and the President replace Obamacare with something like what the House has cooked up, that’ll change, because GINA will be the only way to force insurance companies to cover people with preexisting conditions…

May 28, 2017: Donald J. Trump @realDonaldTrump tweeted: “I suggest that we add more dollars to Healthcare and make it the best anywhere. ObamaCare is dead – the Republicans will do much better!”

June 14, 2017: The Associated Press posted an article titled: “AP Sources: Trump tells senators House health bill ‘mean'”. From the article:

President Donald Trump told Republican senators Tuesday that the House-passed health care bill he helped revive is “mean” and urged them to craft a version that is “more generous,” congressional sources aid.

Trump’s remarks were a surprising slap at a Republican-written House measure taht was shepherded by Speaker Paul Ryan, R-Wis., and whose passage the president lobbied for and praised. At a Rose Garden ceremony minutes after the bill’s narrow House passage on May 4, Trump called it “a great plan.”…

…Trump’s comments were described by two GOP congressional sources who received accounts of Tuesday’s White House lunch. They spoke on condition of anonymity to reveal a closed-door conversation…

June 22, 2017: Ballotpedia posted information about the Better Care Reconciliation Act (BCRA). It is the Senate’s version of the American Health Care Act, which was passed by the U.S. House of Representatives on May 4, 2017.  From the information:

The bill is a reconciliation bill, meaning it impacts the budgetary and fiscal provisions of the Affordable Care Act (ACA) – commonly known as Obamacare – and does not contain a provision to repeal the law in its entirety. The bill would repeal the individual and employer mandates, adjust the ACA’s system of tax credits, and end the ACA’s Medicaid expansion. Medicaid funding would also be converted from an open-ended entitlement to a per-member amount.

Highlights of the Senate’s Better Care Reconciliation Plan:

  • Medicaid funding would increase each year by the medical component of inflation plus 1 percentage point until 2025, then would increase according to inflation each year thereafter.
  • The bill would fund cost-sharing reduction payment reimbursements through 2019. The cost-sharing reduction program would end in 2020.
  • The bill would suspend for one year federal funding available for a certain category of community health centers that includes Planned Parenthood.

…The Better Care Act is a reconciliation bill. Reconciliation bills primarily deal with changes in taxes or spending and can bypass potential filibusters in the Senate. Reconciliation bills can pass the Senate with a simple majority of votes (51-49) rather than the 60 vote threshold required to end a Senate filibuster. This means that Senate Republicans would need at least 50 votes to pass the bill, with Vice President Mike Pence casting the tie-breaking 51st vote…

June 22, 2017: Wired posted an article titled: “The Senate Health Bill Is A Disaster for the Opioid Crisis”. It was written by Megan Moteni. From the article:

After seven years of promising to repeal and replace the Affordable Care Act, Senate Republicans are now closer to achieving that goal than before. Thursday morning, they finally unveiled their secretly drafted healthcare bill. It is not, as some hoped, a drastic departure from the House’s version which passed last month. While being slightly less “mean”, in that it provides more financial support to some lower-income groups, the Senate bill still lands punches to Obamacare in all the same places.

It still ends the healthcare mandate that every American be insured. It still gives power to the states to drop many of the essential benefits required by the ACA, including maternity care, emergency services, substance abuse, and mental healthcare treatments. It still ends the Medicaid expansion that helped 20 million people get insured (although one year later than the House proposed). And it places a cap on Medicaid, while simultaneously slashing about $840 billion from the entitlement program over the next 10 years to pay for enormous tax cuts for the wealthy. All of which adds up to very bad news for patients – but especially for the 2.5 million Americans currently struggling with an opioid addiction.

In closed-door sessions this week, Republican senators from states hardest hit by the current drug crisis tried to soften those deep Medicaid cuts by advocating for a separate funding stream of $45 billion over 10 years for substance abuse treatment and prevention. According to data compiled by the Associated Press, that expansion accounted for 61 percent of total Medicaid spending on substance abuse treatment in Kentucky, 56percent in Michigan, and 43 percent in Ohio.

Instead, what they got was a bill that promises to deliver $2 billion for 2018. That’s it…

June 22, 2017: NPR posted an article titled: “CHART: Who Wins, Who Loses With Senate Health Care Bill”.  It includes charts that make it easy to compare The Affordable Care Act (Obamacare), the House American Health Care Act, the Senate Better Care Reconciliation Act, and the Senate Repeal-Only bill.

Here are the details NPR provided about the Senate’s Better Care Reconciliation Act (BCRA):

  • Keeps the Obamacare provision that allows people to stay covered by their parent’s health insurance plan up through age 26. That group is also allowed to buy a plan independent from their parents.
  • The CBO report says 22 million people would lose health insurance over the next 10 years under the BCRA, with people between ages 50 and 64 disproportionately impacted.
  • The oldest people under 65 would pay five times more for health insurance they buy from the exchanges than younger people who buy health insurance from the exchanges.
  • Subsidies to help pay for insurance would be less and end at incomes of 350 percent of poverty level. This would make deductibles in many cases very high.
  • Federal contributions to Medicaid start to decline in fiscal year 2020.
  • A revision to the BCRA allows subsidies to be used to by plans that offer only catastrophic care, and to allow consumers to use health savings accounts to pay for their premiums.
  • Keeps the Obamacare provision that allows skilled nursing care to be covered by Medicare for up to 100 days per illness.
  • Medicaid coverage for nursing home services and payments to nursing homes could be cut as federal payments to states decline.
  • Keeps the part of the Obamacare provision that requires insurance companies to accept all applicants regardless of health status. Removes the part of the Obamacare provision that prevents people with pre-existing medical conditions to be denied health insurance coverage or charged more for their health insurance coverage.
  • The draft of the BCRA allowed states to ask permission to reduce required coverage (“essential health benefits”). The purpose was to give insurers some discretion over what they offered in their plans. This could result in “substantial increases” in costs for people who want those services according to the CBO.
  • If a particular benefit is no longer classified as essential, insurers could impose annual and/or lifetime limits on what they spend on patients for that benefit.
  • Caps on the annual out-of-pocket costs for patients would no longer apply.
  • Removes the Obamacare provision that requires federal programs to reimburse Planned Parenthood for most services.
  • Places a one-year block on federal reimbursements for care provided by Planned Parenthood. The CBO estimates 15 percent of low-income women who already have reduced access to care would completely lose access to family planning care, increasing birthrates and Medicaid spending for childbirth and children’s insurance. But those increases would be offset by Planned Parenthood cuts.
  • Changes the Obamacare provision that states that a person may qualify for Medicare and also Medicaid. The BCRA would still allow a person to qualify for Medicare and also Medicaid, but services covered by Medicaid could be cut as federal funding to states declines over time. The CBO report suggests that by 2026, Medicaid enrollment would fall by more than 15 million people.
  • Removes the Obamacare provision that requires that mental health care be covered by all health insurance plans under essential health benefits.
  • The BCRA allows states to request waivers to opt out of requiring essential health benefits. If a state opted out of coverage for mental health care, insurance that includes mental health care coverage could become “extremely expensive,” the CBO says.
  • Under Obamacare, 31 states and the District of Columbia offered expanded Medicaid coverage to low-income people. The BCRA does not continue that funding.  Instead, the federal funding for Medicaid expansion will phase out between 2021 and 2013. There are 8 states that have a “trigger clause” – if the federal matching rate declines below the Obamacare promised rated, the expansion goes away immediately.
  • The states with a “trigger-clause” are: Arkansas, Illinois, Indiana, Michigan, Montana, New Hampshire, New Mexico and Washington.
  • In 2025, under the BRCA, further reductions to funding for the Medicaid expansion would start.
  • In a separate BRCA provision, states could impose a work requirement on Medicaid recipients. Most able-bodies adult Medicaid recipients already work.
  • Removes the Obamacare provision that requires the wealthy to pay extra taxes to support the ACA (Obamacare).
  • The BRCA would repeal ACA taxes on corporations and the wealthy that pay for insurance subsidies. That would add up to about $563 billion in tax cuts over 10 years, according to the CBO.
  • A BRCA revision keeps some of the ACA’s taxes on higher-income people. But the permission for flexible spending accounts to be used for premium payments will be a tax advantage for those who can afford to put money aside.

June 22, 2017: NPR posted an article titled: “CHART: Who Wins, Who Loses With Senate Health Care Bill”.  It includes charts that make it easy to compare The Affordable Care Act (Obamacare), the House American Health Care Act, the Senate Better Care Reconciliation Act, and the Senate Repeal-Only bill.

Here are the details NPR provided about the Senate’s “Skinny bill” that would, if passed, repeal Obamacare – and not replace it with anything at all:

  • Keeps the Obamacare provision that allows people to stay covered by their parent’s health insurance plan up through age 26. That group is also allowed to buy a plan independent from their parents.
  • According to a CBO report, the repeal bill would repeal major provisions of Obamacare, including the federal Medicaid funding expansion funding, the premium tax credits and cost-sharing subsidies, the individual mandate and the employer mandate.
  • The same CBO report starts that the “Skinny bill” would cause 17 million people would lose health insurance in 2018, rising to 32 million by people by 2026. Premiums on the exchanges would rise by 25 percent in 2018, increasing to 50 pent in 2020.
  • In addition, roughly 10 percent of the population would live in areas where there would not be any insurer in the individual market in 2018. That would rise to half of the nation’s population in 2020, and three-quarters of the population in 2026.
  • Changes the Obamacare provision that requires skilled nursing care to be covered by Medicare up to 100 days per illness and that allows Medicaid to be available (based on income.) The “Skinny bill” would still allow nursing care to be covered by Medicare up to 100 days per illness.  However, Medicaid services or payments to nursing homes could be cut as states see federal funding decline.
  • Changes the Obamacare provision that requires that health insurance coverage cannot be denied to people with pre-existing conditions, and that prevents health insurance companies from charging a higher cost for coverage to people who have preexisting conditions.
  • Instead, insurance companies would be required to accept all applicants regardless of health status. The 10 Obamacare health benefits would also remain in place. But, the provisions that repeal the individual and employer mandate would mean that healthier people would likely drop insurance coverage and prices souls rise for consumers who continued to purchase it – in other words, sicker people.
  • The CBO estimates prices would be about 50 percent higher in 2020 and double by 2026.
  • Removes the Obamacare provision that requires federal programs to reimburse Planned Parenthood for most of their services. The “Skinny bill” would put a one-year block on federal reimbursements for care provided by Planned Parenthood.
  • Changes the Obamacare provision that allows a person to qualify for Medicare and also for Medicaid.
  • The “Skinny bill” would continue to allow a person to qualify for Medicare and also for Medicaid. However, the elimination of federal Medicaid expansion funding could have ripple effects to people with disabilities as states would have to decide whether to make up lost funding, trim services, or limit who can get Medicaid. Laws would remain on the books the Medicaid would need to cover people who have disabilities, but in some states, people could face long waits (months to years) to get those benefits.
  • Changes the Obamacare provision that health insurance plans must cover mental health services under essential health benefits.
  • The “Skinny bill” would still require mental health coverage as one fo the 10 essential health benefits. However, with the individual mandate that requires people to have insurance, it is likely that only people who require robust coverage would continue to purchase it. Prices would go way up for those on the individual market. Essential health benefits would be done away with in Medicaid.
  • Changes the Obamacare Medicaid expansion.  31 states and the District of Columbia offer expanded Medicaid coverage. The “Skinny bill” would phase out the funding for the Medicaid expansion over two years. Eight states have a “trigger clause” that goes into effect if the federal matching rate for Medicaid goes below the Obamacare-promisted rates. If that happens, those states will immediately end their Medicaid expansion. Those states are: Arkansas, Illinois, Indiana, Michigan, Montana, New Hampshire, New Mexico, and Washington.
  • Removes the Obamacare provision that requires the wealthy to pay extra tax to support Obamacare.
  • The “Skinny bill” repeals taxes on corporations and the wealthy. According to the CBO’s July 19 estimate, that would add up to $613 billion in tax cuts over 10 years.

June 26, 2017: The Congressional Budget Office (CBO) posted a report titled “H.R. 1628, Better Care Reconciliation Act of 2017.” From the summary of the report:

The Congressional Budget Office and the staff of the Joint Committee on Taxation (JCT) have completed the direct spending and revenue effects of the Better Care Reconciliation Act of 2017, a Senate amendment in the nature of a substitute to H.R. 1628. CBO and JCT estimate that enacting this legislation would reduce the cumulative federal deficit over the 2017-2026 period by $321 billion. That amount is $202 billion more than the estimated net savings for the version of H.R. 1628 that was passed by the House of Representatives.

The Senate bill would increase the number of people who are uninsured by 22 million in 2026 relative to the number under current law, slightly fewer than the increase in the number of uninsured estimated for the House-passed legislation. By 2026, an estimated 49 million people would be uninsured, compared with 28 million who would lack insurance that year under current law…

  • CBO and JCT estimate that, over the 2017-2026 period, enacting this legislation would reduce deficit spending by $1,022 billion and reduce revenues by $701 billion, for a net reduction of $321 billion in the deficit over that period…
  • The largest savings would come from reductions in outlays for Medicaid – spending on the program would decline in 2026 by 26 percent in comparison with what the CBO projects under current law – and from changes to the Affordable Care Act’s (ACA’s) subsidies for nongroup health insurance… Those savings would be partially offset by the effects of other changes to the ACA’s provisions dealing with insurance coverage: additional spending designed to reduce premiums and a reduction from repealing penalties on employers who do not offer insurance and on people who do not purchase insurance.
  • The largest increases in deficits would come from repealing or modifying tax provisions in the ACA that are not directly related to health insurance coverage, including repealing a surtax on net investment income and repealing annual fees imposed on health insurers.

…CBO and JCT estimate that, in 2018, 15 million more people would be uninsured under this legislation than under current law – primarily because the penalty for not having insurance would be eliminated. The increase in the number of uninsured people relative to the number projected under current law would reach 19 million in 2020 and 22 million in 2026. In later years, other changes to the legislation – lower spending on Medicaid and substantially smaller average subsidies for coverage in the nongroup market – would also lead to increases in the number of people without health insurance. By 2026, among people under age 65, enrollment in Medicaid would fall by about 16 percent and an estimated 49 million people would be uninsured, compared with 28 million who would lack insurance that year under current law…

…Under This Legislation. CBO and JCT anticipate that, under this legislation, nongroup insurance markets would continue to be stable in most parts of the country. Although substantial uncertainty about the effects of the new law could lead some insurers to withdraw from or not enter the nongroup market in store states, several factors would bring about market stability in most states before 2020. In the agencies’ view, those key factors include the following: subsidies to purchase insurance, which would maintain sufficient demand for insurance by people with health care expenditures; the appropriation of funds for cost-sharing subsidies, which would provide certainty about the availability of those funds; and additional federal funding provided to states and insurers, which would lower premiums by reducing the costs to insurers of people with high care expenditures.

The agencies expect that the nongroup market in most areas of the country would continue to be stable in 2020 and later years as well, including in some states that obtain wavers that would not have otherwise done so. (Under current law and this legislation, states can apply for Section 1332 waivers to change the structure of subsidies for nongroup coverage; the specifications for essential health benefits [EHB’s], which set the minimum standards for the benefits in the nongroup and small-group markets must cover; and other related provisions of the law.) Substantial federal funding to directly reduce premiums would be available through 2021. Premium tax credits would continue to provide insulation from changes in premiums through 2021 and in later years. Those factors would help attract enough relatively healthy people for the market for most areas of the country to be stable, CBO and JCT anticipate. That stability in most areas would occur even though the premium tax credits would be smaller in most cases than under current law and subsidies to reduce cost-sharing – the amount that consumers are required to pay out of pocket when they use health care services – would be eliminated starting in 2020.

In the agencies’ assessment, a small fraction of the population resides in areas which – because of this legislation, at least for some of the years after 2019 – no insurers would participate in the nongroup market or insurance would be offered only with very high premiums. Some sparkly populated areas might have no nongroup insurance offered because the reduction in subsidies would lead fewer people to decide to purchase insurance – and markets with few purchasers are less profitable for insurers. Insurance coverage certain services would become more expensive – in some cases, extremely expensive – in some areas because of the scope of the EHBs [essential health benefits] would be narrowed through waivers affecting close to half the population, CBO and JCT expect. In addition, the agencies anticipate that all insurance in the nongroup market would become very expensive for at least a short period of time for a small fraction of the population residing in areas in which states’ implementation of waivers with major changes caused market disruption.

The legislation would increase average premiums in the nongroup market prior to 2020 and lower average premiums thereafter, relative to projections under current law, CBO and JCT estimate. To arrive at those estimates, the agencies examined how the legislation would affect the premiums charged if people purchased a benchmark plan in the nongroup market.

In 2018 and 2019, under current law and under the legislation, the benchmark plan has an actuarial value of 70 percent – that is, the insurance pays about 70 percent of the total cost of covered benefits, on average. In the marketplaces, such coverage is known as a silver plan.

Under the Senate bill, average premiums for single individuals would be about 20 percent higher in 2018 than under current law, mainly because the penalty for not having insurance would be eliminated, inducing fewer comparatively healthy people to sign up. Those premiums would be about 10 percent higher than under current law in 2019 – less than in 2018 in part because funding provided by the bill to reduce premiums would affect pricing and because changes in the limits on how premiums can vary by age would result in a larger number of younger people paying lower premiums to purchase policies.

In 2020, average premiums for benchmark plans for single individuals would be about 30 percent lower than under current law.  A combination of factors would lead to that decrease – most important, the small share of benefits paid for by the benchmark plans and federal funds provided to directly reduce premiums…

…Under this legislation, starting in 2020, the premium for a silver plan would typically be a relatively high percentage of income for low-income people. The deductible for a plan with an actuarial value of 58 percent would be a significantly higher percentage of income – also making such a plan unattractive, but for a different reason. As a result, despite being eligible for premium tax credits, few low-income people would purchase any plan, CBO and JCT estimate…

…Some people enrolled in nongroup insurance would experience substantial increases in what they would spend on health care even through benchmark premiums would decline, on average, in 2020 and later years. Because nongroup insurance would pay for a smaller average shares of benefits under this legislation, most people purchasing it would have higher out-of-pocket spending on health care than under current law. Out-of-pocket spending would also be affected for the people – close to half the population , CBO and JCT expect – living in stats modifying the EHBs using waivers. People who used services or benefits no longer included in EHBs would experience substantial increases in supplemental premiums or out-of=pocket spending on health care, or would choose to forgo the services. Moreover, the ACA’s ban on annual and lifetime limits on covered benefits would no longer apply to health benefits not defined as essential in a state. As a result, for some benefits that might be removed from a state’s definition of EHBs but that might not be excluded from coverage altogether, some enrollees could see large increases in out-of-pocket spending because annual or lifetime limits would be allowed…

June 30, 2017: USA Today posted an article titled: “President Trump to Senate GOP: Repeal Obamacare now”. It was written by Jessica Estepa and Eliza Collins. From the article:

President Trump suggested Friday that Senate Republicans may not be able to push through their health care plan meant to repeal and replace Obamacare and suggested a conservative-endorsed alternative instead…

The article pointed out that on June 30, 2017,  Donald J. Trump @realDonaldTrump tweeted: “If Republican Senators are unable to pass what they are working on now, they should immediately REPEAL and then REPLACE at at later date!”

…It’s the second time this week that Trump seemed to recognize how difficult it may be to get this bill through the Senate. On Monday, he said on Twitter, “Republican Senators are working very hard to get there, with no help from the Democrats. Not easy! Perhaps just let Care crash & burn!”

A day later, as Republican opposition to the legislation grew, Senate Majority Leader Mitch McConnell of Kentucky announced that he would postpone a vote on the legislation until after the July Fourth recess.

McConnell needs at minimum 50 of the 52 Republicans in the Senate to vote on the bill. Currently, there are at least eight senators outright opposed to the legislation and a handful of others who have expressed concern….

July 11, 2017: Bloomberg posted an article titled: “America’s Rich Will Get Richer, Its Poor Poorer With Obamacare Repeal”. It was written by John Tozzi. From the article:

…Since the 1970s, as America’s income gap has widened, one of the most powerful drivers of inequality has been the growing cost of health care. The ACA, President Barack Obama’s signature domestic achievement, expanded the safety net for people such as [Jane] Harrod, who lived one bad turn away from financial disaster, extending coverage to about 20 million Americans and cutting the share of uninsured by almost half since 2013.

Soon, it may be a thing of the past. Senate Republicans having returned from their July 4 break, resumed negotiations to replace Obamacare with legislation that could lead to 15 million fewer people being insured next year, and 22 million fewer by 2026,according to the non partisan Congressional Budget Office.

Some insurers are exiting the state marketplaces created by the ACA, leaving parts of the country with no insurers selling Obamacare plans. Republicans cite these departures as evidence that the law is failing and needs to be replaced. Senate Majority Leader Mitch McConnell, a Kentucky Republican, has said that a bipartisan plan to stabilize the marketplaces will be needed if his divided caucus can’t agree on a replacement. Democrats counter that the shaky state of Obamacare is directly related to a refutably Republicans to support it since its passage…

…The Senate bill in its current form would cut taxes on the wealthy and the medical industry, reduce subsidies for insurance coverage, and, for the first time in U.S. history, cap the growth of federal Medicaid spending. The proposed reductions in this state-federal program for low income and disabled people, created under President Lyndon Johnson as part of his Great Society initiatives, “dwarfs the increases that occurred through the ACA”, said Henry Aaron, a Brookings Institution economist…

July 13, 2017: Senators Lindsey Graham (Republican- South Carolina) and Bill Cassidy (Republican – Louisiana) released a proposal to modify the Affordable Care Act (ACA) also known as Obamacare. Ballotpedia has detailed information about what has been called the Graham-Cassidy Obamacare replacement plan. From Ballotpedia:

…The plan was also introduced as an amendment to the Better Care and Reconciliation Act during the Republican effort to repeal the ACA in July 2017. The proposal is a reconciliation bill, which would only impact the budgetary and fiscal provisions of the ACA. The bill does not contain a provision to repeal the law in its entirety. Instead, the bill would keep in place most of the ACA’s taxes and fees and send that money to the states for them to make changes to health insurance and healthcare at the state level….

Ballotpedia provided the following highlights of Graham-Cassidy:

  • The proposal would repeal the federal premium tax credits and the cost-sharing reductions provided to individuals under the ACA. States could create their own system of tax credits and subsidies if they chose.
  • The federal requirements for individuals to obtain health insurance and for employers to offer it would be effectively eliminated by reducing the penalty to $0. States could establish their own requirements, if they chose.
  • The plan would appropriate $1.18 trillion between 2020 and 2026 for a healthcare grant program for states that could be used to establish programs or policies to help cover high-risk individuals, stabilize premiums, and reduce out-of-pocket costs.

SCRIBD posted the full text of H.R. 1628 (the Graham-Cassidy proposal). The full title is “To provide for reconciliation pursuant to title II of the concurrent resolution on the budge for the fiscal year 2017).

Ballotpedia provides an easy-to-understand explanation of what H.R. 1628 (Graham-Cassidy) would do:

  • It would repeal the federal premium tax credits and the cost-sharing reductions provided to individuals under the ACA. States could create their own system of tax credits and subsidies if they chose.
  • Under the proposal, tax credits using federal funds could not be used for plans that cover abortions except for those necessary to save the life of the mother or in cases of raper or incest. The bill would suspend federal funding to community health centers that provide family planning, reproductive health, and related medical services and that also provide abortions for reasons other than rape or incest or to save the life of the mother. This would include Planned Parenthood. The funding would be suspended for one year.
  • The federal requirements for individuals to obtain health insurance (the “individual mandate”) and for employers to offer it (the “employer mandate”) would be eliminated by reducing the penalty to $0. States could establish their own requirements if they chose.
  • In place of federal tax credits, cost-sharing reductions, and the Medicaid expansion, the proposal would fund a grant program for states to design their own systems for health insurance and healthcare. That funding could be used to establish programs or policies to help cover high-risk individuals, stabilize premiums, and reduce out-of-pocket costs. $1.18 trillion would be appropriated between 2020 and 2026 for the grant program.
  • Funding for the grant program would be allocated using a formula based on the amount of ACA-related federal funding provided to a state for the Medicaid expansion, tax credits, and cost-sharing reductions and the number of low-income individuals in a state.
  • States, when applying for grants, could request waivers from ACA provisions including: the provision that restricts the extent insurers can vary premiums based on age or other factors (except restrictions on variations based on sex or other protected classes of individuals), the provision that prohibits health insurers from varying premiums based on preexisting conditions, the provision that requires health insurers to cover a standard set of health benefits, and the provision that requires insurers to provide rebates to consumers if they do not spend a minimum percentage of premium revenue on medical services.
  • Insurers would still be required to keep dependents to remain on their parent’s health insurance coverage until age 26.
  • Insurers would still be prohibited from denying coverage for pre-existing conditions. As noted above, insurers would not be prohibited from charging higher premiums for people who have pre-existing conditions.
  • The proposal would establish a fund of $25 billion to pay out to insurers to mitigate disruptions to health insurance coverage and address urgent health care needs. Those funds would be paid to insurers in 2019 and 2020.
  • The bill does not fund cost-sharing reduction reimbursements. It ends that program in 2020.
  • Beginning in 2020, the bill would end the part of the Medicaid expansion that allowed states to expand eligibility for their Medicaid programs to childless adults earning incomes below 138 percent of the poverty level. The Graham-Cassidy bill would end this Medicaid expansion and all federal funding for it on January 1, 2020.
  • There is a complex situation in the bill regarding changes to the Medicaid program funding. The key thing to know is that states could apply to receive their Medicaid funding as a block grant. The bill would set a target spending amount for states based on their Medicaid spending during a past two-year period. States that spent more than their targeted amount on their Medicaid programs in a given year would receive less Medicaid funding the following year.
  • States would be required to reevaluate the eligibility of Medicaid enrollees every six months. States would be allowed to include a work requirement for non-disabled, non-elderly, non-pregnant adults under Medicaid.
  • The bill proposes that individuals with high-deductible health plans use health savings accounts (HSAs) to pay premiums in excess of the amounts already credited or deducted through the federal tax code. The plan would increase the limit on annual HSA contributions to the combined amount of the deductible and the limit on out-of-pocket spending.
  • The tax penalty for withdrawals from health savings accounts for non-medical expenses would be reduced from 20 percent to 10 percent.
  • The ACA tax on over-the-counter medications and 2.3 percent excise tax on medical devices would be repealed.
  • The bill does not repeal the 40 percent excise tax on high cost employer-sponsored health coverage (known as the Cadillac tax).

July 17, 2017: Donald J. Trump @realDonaldTrump tweeted: “Republicans should just REPEAL failing ObamaCare now & work on a new Healthcare Plan that will start from a clean slate. Dems will join in!”

July 21, 2017: Ballotpedia posted information about the Senate’s Better Care Reconciliation Act (BCRA).  It is the Senate’s version of the American Health Care Act, which was passed by the U.S. House of Representatives on May 4, 2017.  From the information:

The Senate Parliamentarian rules on whether or not provisions of reconciliation bills meet the rules such bills are required to follow. The Senate Parliamentarian ruled that five provisions in the revised BCRA did not meet the rules of reconciliation:

  • The provision suspending funding for Planned Parenthood for one year
  • The provision prohibiting the use of tax credits for plans that cover abortion in circumstances other than rape or incest or to save the life of the mother.
  • The provision appropriating funding for cost-sharing reductions.
  • The provision requiring insurers to enforce a six-month waiting period on coverage for individuals who could not prove that they’d had continuous health insurance for the previous 12 months.
  • The provision prohibiting New York from receiving federal reimbursement for Medicaid payments that counties make to the state.

July 22, 2017: Donald J. Trump @realDonaldTrump tweeted: “I am very supportive of the Senate #HealthcareBill. Look forward to making it really special! Remember, ObamaCare is dead.”

July 22, 2017: Donald J. Trump @realDonaldTrump tweeted: “ObamaCare is dead and the Democrats are obstructionists, no ideas or votes, only obstruction. It is solely up to the 52 Republican Senators!”

July 25, 2017: The U.S. Senate voted on a procedural vote on the Better Care and Reconciliation Act (BCRA). The vote was 43 YEAS to 57 NAYS. This means it did not pass. It needed to have 60 YEAS for it to pass.

The majority of the Republican Senators voted YEA. A few Republican Senators voted NAY:

  • Susan Collins (Maine)
  • Bob Corker (Tennessee)
  • Tom Cotton (Arkansas)
  • Lindsey Graham (South Carolina)
  • Dean Heller (Nevada)
  • Mike Lee (Utah)
  • Jerry Moran (Kansas)
  • Lisa Murkowski (Alaska)
  • Rand Paul (Kentucky)

All of the Democratic Senators, and both of the Independent Senators voted NAY.

July 25, 2017: The New York Times posted an article titled: “Senate Votes Down Broad Obamacare Repeal”. It was written by Thomas Kaplan and Robert Pear. From the article:

The Senate voted narrowly on Tuesday to begin debate on a bill to repeal major provisions of the Affordable Care Act, but hours later, Republican leaders suffered a setback when their most comprehensive plan to replace President Obama’s health law fell far short of the votes it needed.

The Tuesday night tally needed to reach 60 votes to overcome a parliamentary objection. Instead, it fell 43-57. The fact that the comprehensive replacement plan came up well short of even 50 votes was an ominous sign for Republican leaders still seeking a formula to pass final health care legislation this week.

For Republicans, the failure ended the day on a sour note, hours after a more triumphant scene on the Senate floor. Lawmakers for both parties had risen to their feet in the afternoon and applauded when Senator John McCain, Republican of Arizona, showed up in the chamber despite his diagnosis of brain cancer. He cast a crucial vote in favor of opening what promises to be a freewheeling, hard-fought debate over the future of the Affordable Care Act.

The 51-50 vote to start debate, with Vice President Mike Pence breaking the tie, came only a week after the Republican effort to dismantle a pillar of Mr. Obama’s legacy appeared all but doomed. It provided an initial win for President Trump, who pushed, cajoled, and threatened senators in recent days to begin debating the health care law….

…The Senate is now moving ahead with the debate, amendments and ultimately a final vote in the coming days of the legislation that would have a profound effect on the American health care system – roughly one-sixth of the United States’ economy. But it is entirely possible that by week’s end, the senators will have passed nothing…

…Only two Republicans, Susan Collins of Maine and Lisa Murkowski of Alaska, voted against the procedural motion, though at least several other Republicans had been seen as possible holdouts. No Democrats voted in favor of the motion…

…The Tuesday night vote was on a comprehensive amendment that included disparate proposals calculated to appeal to conservatives and moderates in the Republican caucus.

One proposal, offered by Senator Ted Cruz, Republican of Texas, would have allowed insurers to sell stripped-down plans, without maternity care or other benefits required by the Affordable Care Act, if they also sold plans that included such benefits…

…The amendment also included money to help pay out-of-pocket medical costs for low-income people, including those who buy private insurance after losing Medicaid coverage as a result of the Senate bill. This proposal was devised by Senator Rob Portman, Republican of Ohio, and other senators from states that have expanded Medicaid under the Affordable Care Act.

But nine Republicans, spanning the party’s ideological spectrum, voted against the package…

…Before senators voted to start the debate in mid afternoon, protestors in the Senate gallery chanted, “Kill the bill, don’t kill us!” and “Shame, shame, shame!”

Despite his vote to move ahead, Mr. McCain offered harsh words for the secretive process by which Senate Republican leaders came up with their process to repeal and replace the health law, and he delivered a pessimistic take on its chances…

…Given the divisions within their caucus, Senate Republican leaders were considering a new approach to keeping their repeal quest alive: They could try to reach an agreement on a slimmed-down bill that would repeal a few major provisions of the Affordable Care Act, like the penalties imposed on people to their employers. Republican leaders would not intend such a bill to become law, but they believe it could win approval in the Senate.

That “skinny” bill could then be a basis for negotiations with the House.

Republican leaders in Congress have struggled all year to fulfill their promise of repealing the 2010 health care law. By a vote of 217 to 213, the House approved a repeal bill in early May, but only after Republicans overcame their own difficulties in that chamber.

Mr. Trump kept up pressure on the Senate on Tuesday with Twitter posts. After the procedural vote, he applauded the Senate, but was cutting towards Ms. Collins and Ms. Murkowski: “We had two Republicans that went against us, which is very sad, I think. It’s very, very, sad for them.”…

…The proposal resembles a bill passed by the Senate in 2015 and vetoed by Mr. Obama in early 2016. But it would increase the number of people who were uninsured by 32 million in 2026, the budget office said…

July 25, 2017: Donald J. Trump @realDonaldTrump tweeted: “Big day for HealthCare. After 7 years of talking, we will soon see whether or not Republicans are willing to step up to the plate!”

July 25, 2017: Ballotpedia posted information about the Senate’s Better Care Reconciliation Act (BCRA).  It is the Senate’s version of the American Health Care Act, which was passed by the U.S. House of Representatives on May 4, 2017.  From the information:

The Senate Parliamentarian ruled that two more provisions do not meet reconciliation rules:

  • The provision allowing insurers to charge older consumers premiums up to five times greater than those charged for younger consumers
  • The provision that allows small businesses to pool together to offer association health plans.

…Due to the rulings, these provisions would need 60 votes to remain on the bill…

July 25, 2017: Donald J. Trump @realDonaldTrump tweeted: “ObamaCare is torturing the American People. The Democrats have fooled the people long enough. Repeal or Repeal & Replace! I have pen in hand.”

July 25, 2017: Donald J. Trump @realDonaldTrump tweeted: “So great that John McCain is coming back to vote. Brave – American hero! Thank you John”.

July 25, 2017: CNN posted an article titled: John McCain returns to Senate, casts vote to advance health care bill” It was written by Ashley Killough and Dylan Stafford. From the article:

Sen. John McCain returned to the Senate on Tuesday to cast one of the final and crucial votes on a procedural step to advance the Republican’s plans to repeal and replace the Affordable Care Act.

McCain, who had been recovering from surgery in Arizona, flew to Washington and was greeted by a standing ovation on both sides of the aisle on the Senate floor when he arrived just minutes before 3 p.m. ET…

He waved and gave the thumbs up to reporters crowded in Capitol’s hallways before casting his vote…

…McCain was essential to advance the legislation. Senate Majority Leader Mitch McConnell could only afford to lose two votes of his 52-member conference in order to pass, and both Sens. Susan Collins of Maine and Lisa Murkowski of Alaska voted against the step. Vice President Pence had to break the 50-50 tie…

…While he voted to proceed to debate on the bill, McCain emphatically stated that he will not vote for the bill as it now stands.

“It’s a shell of a bill right now, and we all know that,” he said, adding that his support hinges on whether the bill includes changes supported by his own governor. McCain has expressed concerns about Medicaid cuts in the bill, something many GOP governors have opposed…

July 25, 2017: Donald J. Trump @realDonaldTrump tweeted: “This will be a very interesting day for HealthCare. The Dems are obstructionists but the Republicans can have a great victory for the people!”

July 25, 2017: Ballotpedia reported the following information about the Senate’s Better Care Reconciliation Act (BRCA):

On the evening of July 25, 2017, the Senate rejected a procedural vote on the BCRA that included amendments to provide funding to help individuals in states that expanded Medicaid pay for deductibles and copays if they lost coverage and to allow insurance companies to sell plans that did not meet the ACA’s requirements. The vote was 43-57.

July 26, 2017: The Senate voted on an amendment that, if passed, would be a partial repeal of Obamacare. The vote was 45 YEAs to 55 NAYs. This means the partial repeal amendment did not pass.

Most of the Republican Senators voted YEA. Some Republican Senators voted NAY:

  • Susan Collins (Maine)
  • Lisa Murkowski (Alaska)
  • John McCain (Arizona)
  • Dean Heller (Nevada)
  • Lamar Alexander (Tennessee)
  • Shelley Moore Capito (West Virginia)
  • Rob Portman (Ohio)

All of the Democratic Senators, and both of the Independent Senators, voted NAY.

July 27, 2017: Ballotpedia posted information about the Senate’s Better Care Reconciliation Act (BCRA).  It is the Senate’s version of the American Health Care Act, which was passed by the U.S. House of Representatives on May 4, 2017.  From the information:

  • The Senate Parliamentarian ruled that the provision changing the conditions for states to get waivers from ACA requirements did not meet reconciliation rules.
  • At least four Republican senators said they would vote no on the revised version of the BCRA which included the provisions that the Senate Parliamentarian ruled did not meet reconciliation rules: Senator Rand Paul (Republican – Kentucky), Senator Susan Collins (Republican – Maine), Senator Jerry Moran (Republican – Kansas) and Senator Mike Lee (Republican – Utah).

July 27, 2017: Ben Jacobs, political reporter for The Guardian, @Bencjacobs tweeted: “McCain releases a statement”. Here is what Senator John McCain’s statement said:

U.S. Senator John McCain (R-AZ) released the following statement today on voting “no” on the so-called “skinny repeal” of Obamacare:

“From the beginning, I have believed that Obamacare should be repealed and replaced with a solution that increases competition, lowers costs, and improves care for the American people. The so-called ‘skinny repeal’ amendment the Senate voted on today would not accomplish those goals. While the amendment would have repealed some of Obamacare’s most burdensome regulations, it offered no replacement to actually reform our health care system, and deliver affordable, quality health care to our citizens. The Speaker’s statement that the House would be ‘willing’ to go to conference does not ease my concern that this shell of a bill could be taken up and passed at any time.

“I’ve stated time and time again that one of the major failures of Obamacare was that it was rammed through Congress by Democrats on a strict-party line basis without a single Republican vote. We should not make the mistakes of the past that has led to Obamacare’s collapse, including in my home state of Arizona where premiums are skyrocketing and health care providers are fleeing the marketplace. We must now return to the correct way of legislating and send the bill back to committee, hold hearings, receive input from both sides of aisle, heed the recommendations of nation’s governors, and produce a bill that finally delivers affordable health care for the American people. We must do the hard work our citizens expect of us and deserve.”

July 29, 2017: The Senate voted on the “Skinny bill” – which would, if passed, repeal Obamacare and replace it with nothing at all.  The vote was 49 YEAs to 51 NAYS. This means the bill did not pass.

The majority of the Republican Senators voted YEA. A few Republican Senators voted NAY:

  • Susan Collins (Maine)
  • Lisa Murkowski (Alaska)
  • John McCain (Arizona)

All of the Democratic Senators, and both of the Independent Senators, voted NAY.

July 28, 2017: The New York Times posted an article titled: “McCain Provides a Dramatic Finale on Health Care: Thumb Down”. It was written by Carl Hulse. From the article:

All week long, Senate Democrats had quietly groused that Senator John McCain made a stirring return to the Senate after a brain cancer diagnosis, that he preached the virtues of bipartisanship – and that he then backed a Republican-only push to replace the Affordable Care Act.

But early Friday morning, Mr. McCain, showing little sign of his grave illness, strode onto the Senate floor as the vote was being taken to repeal it, and shocked many of his colleagues and the nation. He sought recognition from the vote counters, turned his thumb down, and said “no”. There were gasps and some applause.

He had just derailed the fevered Republican effort to undo the Obama-era health care law.

It was a stunning moment that will be long remembered in the Senate, a flash of the maverick John McCain, unafraid of going his own way despite the pleas of his fellow Republicans. In teaming up with Senators Susan Collins of Maine and Lisa Murkowski of Alaska, who had already opposed the bill, Mr. McCain made good on his earlier promise to help defeat the measure if it didn’t meet his personal test…

July 29, 2017: Donald J. Trump @realDonaldTrump tweeted: “Unless the Republican Senators are total quitters, Repeal and Replace is not dead! Demand another vote before voting on any other bill!”

August 1, 2017: The New York Times posted an article titled: “Republicans in Congress Bypass Trump to Shore Up Health Law”. It was written by Robert Pear and Thomas Kaplan. From the article:

Congressional Republicans moved on Tuesday to defuse President Trump’s threat to cut off critical payments to health insurance companies, maneuvering around the president toward bipartisan legislation to shore up insurance markets under the Affordable Care Act.

Senator Lamar Alexander of Tennessee, the influential chairman of the Senate Health, Education, Labor, and Pensions Committee, announced that his panel would begin work in early September on legislation to “stabilize and strengthen the individual health insurance market” for 2018. He publicly urged Mr. Trump to continue making payments to health insurance companies to reimburse them for reducing the out-of-pocket medical expenses of low-income people.

In the House, two Republicans, Representatives Tom Reed of New York and Charlie Dent of Pennsylvania, teamed with Democrats to promote incremental health legislation that would also fund the cost-sharing subsidies.

The moves were a remarkable response to the president’s repeated threats to send insurance markets into a tailspin. They offered tangible indications of cooperation between the parties after Republican efforts to scrap the Affordable Care Act collapsed in the Senate last week, all but ending the seven-year Republican quest to overturn President Barack Obama’s signature domestic ability. Lawmakers from both parties concede that the health law needs improvement, as consumers face sharp premium increases and a shrinking number of insurance options in many states.

These problems have been exacerbated by a president who has publicly predicted that the Affordable Care Act will “implode” and appears determined to help fulfill that prophecy. Mr. Trump has repeatedly threatened to cut off the subsidies, known as cost-sharing reduction payments, which reimburse insurers for cutting deductibles and other out-of-pocket costs for millions of low-income people. Without them, insurers would almost certainly raise premiums not only for poor consumers but also for many other people buying plans on the individual market…

…In the House, a group of members known as the Problem Solvers Caucus announced agreement this week on a bipartisan set of proposals to stabilize insurance markets and revise the Affordable Care Act to provide relief to consumers and small and midsize businesses. The proposals would provide money for cost-sharing reduction payments, repeal a tax on medical devices and exempt businesses with fewer than 500 employees from the law’s requirements to offer health insurance to workers…

…Under the proposal, funds for the cost-sharing payments would be guaranteed, and Congress could review use of the money each year, just as it reviews other federal spending…

…Payment of the cost-sharing subsidies is a top priority for insurers and for Democrats in Congress, who say that cutting off the payments would cause havoc in the insurance markets.

The president has the power to stop the payments because a federal judge ruled last year that the Obama administration had been illegally making the payments, in the absence of a law explicitly providing money for the purpose…

August 1, 2017: The Sacramento Bee posted an article titled: “Covered California announces 12.5 percent premium hikes in 2018, but what’s this new surcharge?”  It was written by Cathie Anderson. From the article:

California consumers buying insurance for 2018 through the state’s insurance exchange will see average premiums increase 12.5 percent, but by comparison pricing, many could limit their premium hikes to 3.3 percent, Covered California officials announced Tuesday.

The increase was a little lower than the average 13.2 Covered California premium hike implemented this year, despite uncertainty over the future of the Affordable Care Act amid Republican attempts to repeal the law. The average 2018 increase was also much lower than premium hikes in several other states…

…That “ongoing uncertainty” could mean that roughly 650,000 consumers who buy Covered California’s most popular insurance plans, those in the silver tier, will face a double whammy on their premium prices. The exchange said it may have to add a 12.4 percent surcharge to premiums in that tier because insurers are worried about continued federal funding that lowers out-of-pocket costs for enrollees.

The good news is that those policy holders won’t feel the full force of that increase. That’s because of a cap on out-of-pocket costs for policy holders whose income is 250 percent of the federal poverty level. Once consumers hit that out-of-pocket ceiling, Medi-Cal will pick up the tab.

Rate hikes are being implemented to guarantee insurers they’ll be reimbursed for discounts they are required to give consumers in the popular silver tier plans. The Affordable Care Act, commonly called Obamacare, mandates that co-pays and other fees be reduced on a sliding scale, depending on income.

But in a major flaw in the law, the U.S. House of Representatives created no mechanism to appropriate funds to reimburse insurers for those discounts. Under the Obama administration, the Department of Health and Human Services set aside the funds annually and paid it, but a lawsuit by House Republicans has challenged the constitutionality of those payments.

The Trump administration has committed to paying those so-called cost-sharing reductions only a month at a time, leaving insurers unwilling to commit to yearlong contracts with health exchanges such as Covered California…

…Covered California said that the silver-tier plans would no longer be a good option for consumers who receive no subsidy and that its representatives and independent insurance advocates would work to get out the message. All the rate changes must be approved by state regulators before the can be implemented.

August 30, 2017: A bipartisan collation of Governors posted a Blueprint for Stronger Health Insurance Markets.

They sent this information to Speaker of the House Paul Ryan (R. Wis.), Senate Majority Leader Mitch McConnell (R. Kentucky), House Minority Leader Nancy Pelosi (D- Ca.) and Senate Minority Leader Charles Schumer (D- NY).  They also posted the information on Governor of Ohio, John Kasich’s website. From the Blueprint:

As Congress considers reforms to strengthen our nation’s health insurance system, we ask you to take immediate steps to make coverage more stable and affordable. The current state of our individual market is unsustainable and we can all agree this is a problem the needs to be fixed. Governors have already made restoring stability and affordability in this market a priority, and we look forward to partnering with you in this effort.

Most Americans currently have access to a stable source of health insurance through their employer, or from public programs, like Medicare and Medicaid. While rising costs are a concern throughout the system, the volatility of the individual market is most immediate concern, threatening coverage for 22 million Americans.

Continuing uncertainty about the direction of federal policy is driving up premiums, eliminating competition, and leaving consumers with fewer choices. Proposed premiums for the most popular exchange plans are expected to increase 18 percent in 2018 and 2.5 million residents in 1,400 countries will have only one carrier available to them on the exchange. Despite these headwinds, states continue to try to stabilize the individual market and have developed innovative solutions to preserve coverage while making insurance more affordable…

From here, the Governors provide details about a plan that they recommend. It includes:

  • Immediate federal action to stabilize markets
  • Responsible reforms that preserve recent coverage gains and controls costs
  • An active federal/state partnership that is based on innovation and a shared commitment to improve overall health system performance.

Here are some key parts of their plan for “Immediate federal action to stabilize markets:

  • Congress needs to send a strong signal now that the individual market will remain viable this year, next year, and into the future.  This is emphasized because the Governors are aware that insurers have until the end of September to make final decisions about participating in the marketplaces.
  • The Trump Administration should commit to making cost reduction (CSR) payments. The Congressional Budget Office (CBO) estimates that not making these payments would drive premiums 20-25 percent and increase the federal deficit $194 billion over ten years. The Governors also want Congress to explicitly appropriate federal funding for the CSR payments at least through 2019. Doing so would put to rest any uncertainty about the future of CSR payments.
  • Congress should create a fund that states can use to create reinsurance programs or similar programs that reduce premiums and limit losses for providing coverage. The Governors recommend funding the program for at least two years and fully offsetting the costs so it does not add to the deficit.
  • The Governors ask Congress to encourage insurance companies to enter underserved counties by exempting these insurance from the federal health insurance tax on their exchange plans in those counties. The Governors also want Congress to allow residents in underserved counties to buy into the Federal Employee Benefit Program, giving rural counties access to the same health care as federal workers.
  • The Governors recommend Congress should leave the individual mandate in place until it can devise a credible replacement. The Governors note that the individual mandate is unpopular, but is important because it provides incentive for healthy people to enroll in health insurance coverage.

Here are some key parts of their plan for “Reforms that Preserve Recent Coverage Gains and Controls Costs”:

  • The Governors have a menu of options that individual states may consider or pursue. Each state will choose the state-based approaches that best fits their individual situation.
  • Maximize market participation by increasing coverage uptake among the uninsured would improve the risk pool and set in place a virtuous cycle of lower premiums leading to higher enrollment. The federal government should continue to fund outreach and enrollment efforts that encourage Americans to sign up for insurance. Making insurance more affordable is a key part of increasing participation in the marketplace.
  • Promote appropriate enrollment by preventing people from enrolling in a health insurance plan only when they need health care, stop paying premiums at the end of the year, or purchase exchange plans even though they are eligible for Medicare and Medicaid. This drives up costs in the individual market. Congress and individual states can reverse this effect by shortening grace periods for non-payment of premiums, verifying special enrollment period qualifications, and limiting exchange enrollment for those who are eligible for other programs.
  • The federal government needs to fully fund risk sharing programs (which the ACA created, but the federal government has gone back on). Congress should modify and strengthen federal risk sharing mechanisms, including risk adjustments and reinsurance.
  • The Secretary of Health and Human Services (HHS) should allow states more flexibility in choosing reference plans for the ten essential health benefits (EHB) categories than are currently allowed by regulation.

Here are some key parts of their plan for “An Active Federal/State Partnership”:

  • The Governors urge Congress and federal agencies to work with states to over come constraints and federal law regulations that prevent states from being truly innovative. The Governors urge Congress to work with states and improve the regulatory environment, support state innovation waivers, and control costs through payment innovation.
  • The federal government should not duplicate efforts or preempt state authority to regulate consumer services, insurance products, market conduct, financial requirements for carriers, and carrier and broker licensing in states that already effectively perform those functions.
  • The ACA permits a state to request permission to waive specific portions of the ACA, including the individual and employer mandates, as well as regulations for qualified health plans, essential health benefits, tax credits and subsidies, and exchanges. A state many not waive community rating requirements, prohibitions on preexisting condition exclusions, lifetime maximum coverage limits, preventative care mandates, or coverage for adults as dependents through age 26. To obtain a waiver, a state must demonstrate its plan would not increase the federal deficit, would not reduce the number of people with health coverage, and would not reduce affordability or comprehensiveness of coverage.  Many states want an option for a fast-track waiver.
  • Control costs through payment innovation. The Governors want Congress and the Administration to make a clear commitment to value-based health care purchasing. This could mean Medicare and other federal programs would be allowed to participate in multi-payer State Innovation Models. Payment innovation projects should be funded through the Centers for Medicare and Medicaid Innovation and expanded to the states.
  • The Governors want the Congress and the Administration to take immediate action to stabilize the individual health insurance marketplace.

Here are the Governors who were part of this letter:

  • John Kasich, Governor, State of Ohio (Republican)
  • John Hickenlooper, Governor, State of Colorado (Democratic)
  • Brian Sandoval, Governor, State of Nevada (Republican)
  • Tom Wolf, Governor, State of Pennsylvania (Democratic)
  • Bill Walker, Governor, State of Alaska (Independent)
  • Terence R. McAuliffe, Governor, State of Virginia (Democratic)
  • John Bel Edwards, Governor, State of Louisiana (Democratic)
  • Steve Bullock, Governor, State of Montana (Democratic)

August 31, 2017: CNN posted an article titled: “Trump slashing Obamacare advertising by 90%”. It was written by Tami Luhby. From the article:

The Trump administration plans to spend 90% less on advertising to get people to sign up for Obamacare than former President Obama did last year.

The administration will spend $10 million on promotions during open enrollment season this fall, compared to $100 million a year ago, the Centers for Medicare & Medicaid Services, which administers Obamacare, said Thursday. It will focus on radio and digital ads, as well as email to existing enrollees.

At the same time, it is curing funding for so-called navigators — who help people sign up for coverage– by 41%. The 98 navigator groups will receive a total of $37 million for the coming enrollment season.

With Congress’ effort to repeal and replace Obamacare on hold, all eyes are on whether the Trump administration will work to stabilize or undermine the health reform law. President Trump has repeatedly said Obamacare is dead. He has raised questions about whether he will try to dismantle the law by discontinuing funding for a key set of subsidies or weakening enforcement of the individual mandate.

Another wild card is how the administration will handle open enrollment, which this year will run from November 1 through December 15 – half the length that it did under Obama, who actively promoted the sign-up period. Trump officials have been largely silent about their plans until now, though they have repeatedly said the law is failing Americans.

The administration justified the budget cuts by saying it was basing advertising on effectiveness and performance. Democrats and Obamacare supporters quickly decried the move as sabotage…

…Advertising and outreach, however, are seen as critical to maintaining and boosting Obamacare enrollment. In fact, a bipartisan coalition of governors — led by Republican Governor John Kasich of Ohio and Democratic Governor John Hickenlooper of Colorado — on Wednesday urged the administration to fund outreach and enrollment efforts.

In particular, it helps attract young and healthy consumers who may not feel they need coverage. The sick, who are eager to secure insurance, are more likely to know where to sign up.

This is not the first time the Trump administration has pulled advertising for Obamacare. It halted up to $5 million worth of ads just days after taking office in January. The campaign was intended to alert consumers to the end of the 2017 sign-up period on January 31. Outreach is considered critical in the final days of the enrollment period to remind consumers — particularly younger ones — of the deadline. Sign ups typically surge during this time.

September 7, 2017: The Hill posted an article titled: “New York extends ObamaCare enrollment deadline”. It was written by Jessie Hellman. From the article:

New York will extend its open enrollment period for ObamaCare plans, citing concerns about an earlier deadline set by the federal government.

New York’s open enrollment will now begin on Nov. 1 and end on Jan 31., officials said on Thursday.

The Trump administration cut this year’s open enrollment in half for states that use the federal marketplace. It will end for those states on Dec. 15.

But New York, and some other states that run their own exchanges, have opted to lengthen their enrollment periods…

…California, Colorado, Minnesota, Washington, Massachusetts and Washington, D.C., have all extended their open enrollment periods past the deadline set by the administration…

September 8, 2017: Donald J. Trump @realDonaldTrump tweeted: “Republicans, sorry, but I’ve been hearing about Repeal & Replace for 7 years, didn’t happen! Even worse, the Senate Filibuster Rule will…”

That tweet was followed by a second tweet: “…never allow the Republicans to pass even great legislation. 8 Dems control – will rarely get 60 (vs. 51) votes. It is a Repub Death Wish!”

September 19, 2017: The Hill posted an article titled: “GOP Chairman declares bipartisan ObamaCare fix dead”. It was written by Peter Sullivan. From the article:

The Senate Health Committee chairman on Tuesday released a statement ending a bipartisan effort to find an ObamaCare fix amid a new GOP push to repeal the law.

“During the last month, we have worked hard and in good faith, but have not found the necessary consensus among Republicans and Democrats to put a bill in the Senate leaders’ hands that could be enacted,” Senate Health Committee Chairman Lamar Alexander (R. – Tenn.) said in the statement.

Senate Minority Leader Charles Shumers’s (D. N.Y.) office dismissed Alexander’s statement about the bipartisan efforts, saying the announcement Tuesday was “not about substance” while pointing to the last-ditch GOP repeal push being led by Sens. Lindsey Graham (R – S.C.) and Bill Cassidy (R-La.)…

…The effort at a bipartisan deal to stabilize ObamaCare markets had always faced headwinds, given the polarizing nature of the issue. But the effort faced even higher obstacles in recent days as Republicans refocused on a GOP-only effort to repeal and replace ObamaCare.

That atmosphere made it very difficult to work in a bipartisan way on the law. Alexander acknowledged that to reporters earlier on Tuesday, and also blamed Sen. Bernie Sanders’s (I-Vt.) announcement of single-payer legislation last week for creating a partisan atmosphere as well.

The announcement comes after Speaker Paul Ryan (R – Wis.) and the White House said they would not agree to a bipartisan deal out of the committee, fearing a “bailout” of ObamaCare.

Sen. Patty Murray (Wash.), the top Democrat on the committee, had tried to keep the talks alive…

…The goal of the bipartisan deal was to provide funding for key ObamaCare payments known as cost-sharing reductions in exchange for new flexibilities for states. Democrats blamed Republican leadership for killing the health committee’s bipartisan effort to clear the way for the new repeal effort…

September 20, 2017: Donald J. Trump @realDonaldTrump tweeted: “I would not sign Graham-Cassidy if it dod not include coverage of pre-existing conditions. It does! A great Bill. Repeal & Replace.”

September 20, 2017: Donald J. Trump @realDonaldTrump tweeted: “Rand Paul is a friend of mine but he is such a negative force when it comes to fixing healthcare. Graham-Cassidy Bill is GREAT! Ends Ocare!”

September 20, 2017: Donald J. Trump @realDonaldTrump tweeted: “I hope Republican Senators will vote for Graham-Cassidy and fulfill their promise to Repeal & Replace ObamaCare. Money direct to States!”

September 20, 2017: Donald J. Trump @realDonaldTrump tweeted: “Rand Paul is a friend of mine but he is such a negative force when it comes to fixing healthcare. Graham-Cassidy Bill is GREAT! Ends Ocare!”

September 20, 2017: Avalere posted a press release titled: “Graham-Cassidy-Heller-Johnson Bill Would Reduce Federal Funding to States by $215 Billion”. It was written by Senior Vice President Elizabeth Carpenter and Director Chris Sloan. From the press release:

New analysis from Avalere finds that the Graham-Cassidy-Heller-Johnson (GCHJ) bill to repeal and replace the Affordable Care Act (ACA) would lead to a reduction in federal funding to states by $215B through 2026 and more than $4T over a 20-year period…

…The proposed legislation would repeal the ACA’s Medicaid expansion, premium tax credits, cost sharing reduction (CSR) payments, individual and employer mandates, and the Basic Health Program (BHP). Instead, the bill would provide states with block grants to fund health insurance coverage in their state. The bill would also change the financing structure of the traditional Medicaid population from an open-ended approach to a fixed per capita cap of block grant approach…

…Years 2020 – 2026: By 2026, the bill – compared to current law – would lead to 34 states and DC experiencing funding cuts; 7 states seeing funding reductions above $10B; and 16 states seeing an increase in funding…

A map titled “Figure 1: Changes in Federal Funding, 2026, in Billions” provides more details:

  • Reduction of $50 to $78 billion: California
  • Reduction of $10 to $50 billion: Washington, Oregon, Arizona, New York, Connecticut, New Jersey, Maryland
  • Reduction of $0 to $10 billion: Nevada, Colorado, New Mexico, Alaska, Hawaii, North Dakota, Nebraska, Minnesota, Iowa, Arkansas, Louisiana, Illinois, Michigan, Indiana, Kentucky, Ohio, West Virginia, Pennsylvania, District of Columbia, Rhode Island, Massachusetts, New Hampshire, Vermont, Maine, Florida. North Carolina
  • Increase of $0 to $10 billion: Montana, Idaho, Utah, Wyoming, South Dakota, Kansas, Oklahoma, Missouri, Wisconsin, Tennessee, Mississippi, Alabama, Georgia, South Carolina, Virginia
  • Increase of $10 to $40 billion: Texas

…The bill then creates a funding cliff after 2026, when block grants would need to be re-appropriated.

Years 2020 -2027: Importantly, the block grant funding appropriated in the bill ends after 2026. While funding for 2027 and beyond might be appropriated in the future, the bill currently creates a block grant funding cliff in 2027. The ability of Congress to appropriate additional funding is uncertain and could be constrained by the need to offset the cost. As such, by 2027, states would see significantly larger declines in funding as compared to current law, with 39 states and DC facing funding cuts, and 18 states with reductions of greater than $10B. By 2027, only 11 states would see an increase under GCHJ compared to current law…The bill is projected to reduce total federal funding to states by $489B through 2027…

A map titled: “Figure 2: Changes in Federal Funding, 2020 – 2027, in Billions” provides more details:

  • Reduction of $75 to $129 billion: California
  • Reduction of $10 to $75 billion: Washington, Oregon, Arizona, Colorado, Minnesota, Arkansas, Louisiana, Illinois, Michigan, Kentucky, Ohio, Florida, Pennsylvania, New York, Massachusetts, Connecticut, New Jersey, Maryland, Alaska, Hawaii, District of Columbia
  • Reduction of $0 to $10 billion: Nevada, Idaho, Utah, New Mexico, Montana, North Dakota, Nebraska, Iowa, Indiana, Tennessee, West Virginia, Virginia, North Carolina, District of Columbia, Delaware, Rhode Island, Vermont, New Hampshire, Maine
  • Increase of $0 to $10 billion: Wyoming, South Dakota, Kansas, Oklahoma, Missouri, Wisconsin, Mississippi, Alabama, Georgia, South Dakota
  • Increase of $10 to $30 billion: Texas

…Years 2020 – 2036: Finally, given the long-term impacts of the Medicaid per-capita caps, particularly in the shift to lower per capita cap growth rates in 2025, and lack of block grant funding beyond 2026, all states would see a reduction in federal funds relative to current law by 2026… Federal funding reductions range from $4B in South Dakota to $800B in California…

A map titled “Figure 3: Changes in Federal Funding, 2020 – 2036, in Billions, provides more details:

  • Reduction of $350 to $800 billion: California, New York
  • Reduction of $50 to $350 billion: Washington, Oregon, Arizona, Colorado, New Mexico, Texas, Louisiana, Arkansas, Minnesota, Illinois, Michigan, Indiana, Kentucky, Tennessee, Ohio, Florida, North Carolina, Pennsylvania, Maryland, New Jersey, Connecticut, Massachusetts
  • Reduction of $25 to $50 billion: Nevada, Hawaii, Oklahoma, Missouri, Iowa, Wisconsin, Alabama, Georgia, South Carolina, Virginia, West Virginia
  • Reduction of $4 to $25  billion: District of Columbia, Alaska, Utah, Idaho, Montana, Wyoming, North Dakota, South Dakota, Nebraska, Kansas, Mississippi Vermont, New Hampshire, Maine, Rhode Island

…Block grant funding would be below current federal funding levels under the ACA for Medicaid expansion states, and would end after 2026. Beginning in 2021, funding would be distributed primarily based on each state’s share of population with incomes between 50 and 138% of the federal poverty level (FPL), a range that excludes a significant proportion of people who qualified for exchange premium tax credits and cost-sharing reductions.

Starting in 2024, block grant amounts would be partially determined by the state’s enrolled population in credible coverage – defined as having an actuarial value at least equivalent to the Children’s Health Insurance Program (CHIP) actuarial value; effectively, coverage that has very low-cost sharing and premiums, similar to Medicaid and CHIP today. As such, funding would effectively be allocated according to the number of a state’s 50% to 138% FPL population the state enrolls in coverage that is equivalent to Medicaid and CHIP.

Under the block grants, funding for the coverage expansion programs under the ACA would be reduced, compared to current law, by $95B, or 7% from 2020 through 2026. From 2020, to 2027, the first year for which there is no appropriated federal funding, the federal funding to states would be cumulatively reduced by $326B, or 21%. From 2020 to 2036, that reduction relative to federal law is projected to grow by $3,071B or 71%…

September 20, 2017: ThinkProgress posted an article titled: “Report finds that every state would suffer under Trumpcare”. It was written by Addy Baird. From the article:

The latest attempt by Republicans in Congress to repeal and replace the Affordable Care Act, spearheaded by Sens. Lindsey Graham (R-SC) and Bill Cassidy (R-LA), would reduce federal spending to states by $215 billion over ten years, ultimately decreasing funding for all states according to an analysis released Wednesday.

The bill has the support of President Donald Trump, who has consistently pushed for Republicans to repeal and replace the ACA after repeated failures to do so in recent months…

…While the bill would indeed fulfill the GOP’s years-long unfulfilled promise of repealing and replacing Obamacare, the new analysis, conducted by nonpartisan health consulting firm Avalere (a favorite of the National Governors Association), paints a different picture.

The Graham-Cassidy bill, which is also supported by Sens. Dean Heller (R-NV) and Ron Johnson (R-WI), requires that the funding to states be re-appropriated after 2026, but that re-appropriation is far from certain. The “funding cliff” created by the uncertain re-appropriation means that not only does Avalere estimate a loss of $215 billion over 10 years, but also finds that states would lose an estimated $4 trillion over 2036.

While Graham and Cassidy have often said the bill would benefits smaller, more rural states, Avalere found that every state would ultimately suffer under the law…

…The report also notes that two states that would be among those hit the hardest include Alaska and Arizona, losing 33 and 34 percent of there funding by 2036, respectively…

…Two of the senators from those states – Sens. John McCain (R-AZ) and Lisa Murkowski (R-AK) – are among a small handful of key swing votes that could determine the fate of the bill. Sen. Rand Paul (R-KY) has consistently said he will vote against the bill and Sen. Susan Collins (R-ME) has suggested she may also vote no, with means Republicans can lose just one more vote.

Graham-Cassidy would also gut Medicaid, ultimately repealing the Medicaid expansion offered under the ACA and shifting to a block grant system…

September 20, 2017: The Jimmy Kimmel Live YouTube Channel posted a video titled: “Jimmy Kimmel Fights Back Against Bill Cassidy, Lindsey Graham, & Chris Christie”

September 25, 2017: NPR posted an article titled: “‘Millions’ Fewer Would Have Coverage Under GOP Health Bill, Says CBO Analysis”. It was written by Alison Kodjak. From the article:

The proposal the Senate is considering that would repeal and replace the Affordable Care Act would result in millions losing health insurance and a $133 billion reduction in the deficit by 2026, according to the Congressional Budget Office’s report on the Graham-Cassidy legislation.

The CBO did not have enough time to estimate specifically how many people’s insurance would be affected as it has done when it scored previous repeal bills. But the analysis it released Monday evening said “the number of people with comprehensive health insurance that covers high-cost medical events would be reduced by millions” compared with current law.

The bill, known as Graham-Cassidy, would dismantle the major components of the Affordable Care Act, or Obamacare. Gone would be the subsidies that help people buy insurance, the mandate that requires people to be covered and the expansion of Medicaid.

All the money from those programs would be rolled up and redistributed to states in the form of block grants. Each state would then decide how to spend those funds. Because of that, says the CBO, the number of people without health insurance “could vary widely depending on how states implemented the legislation.”

The bill also changes Medicaid by capping the federal contribution – giving states a fixed amount per person and increasing it at a rate that is slower than health care inflation.

CBO says it cannot do a complete analysis of the plan in the short window requested by lawmakers. Senate Republicans are looking to vote on the bill this week, before a deadline at the end of September would require they get support from Democrats to be able to pass the legislation…

September 25, 2017: ABC News posted an article titled: “What’s different about the revised Graham-Cassidy bill”. It was written by Maryalice Parks and Veronica Stracqualursi. From the article:

…The newest draft from Sens. Bill Cassidy, R-La., Lindsey Graham, R-S.C., Dean Heller, R.Nev., and Ron Johnson, R.Wis., rejiggers how changes in federal funding provided to states for health care would be phased in over time.

As a result, there would likely be less of a gap between the states poised to get additional federal dollars from this bill and the states that would lose out on funding.

The concept of block granting federal funding remains the centerpieces of the legislation. Starting in 2020, the federal government would end stop providing additional money for states that specifically expanded their Medicaid programs under the Affordable Care Act. The bill would also end the cost-sharing subsidies the federal government currently pays to insurance companies to help keep premiums for lower-income Americans buying health insurance. Instead, the plan would designate some federal funds to be divided up to states based on their resident’s poverty levels and other factors that impact health care costs like population density.

The authors have argued that it is unfair that under current law, some states receive more federal funding to help provide health insurance than others, though all states were offered the same opportunity and access to additional funds to expand their Medicaid rolls. Many Republican governors refused that available funding under current law.

The new Republican plan would essentially equalize federal funding between states that expanded Medicaid and states that did not, but the latest version makes those changes more gradually.

States that expanded Medicaid would still likely lose billions of dollars in federal funding, and the overall pot of total federal funding would still be approximately $160 billion less over the next 10 years as compared to current law, according to a study from the Kaiser Family Foundation.

The new draft would also appropriate $500 million specifically to states that set up waiver systems under Obamacare, which only includes Hawaii and Alaska. Alaska Sen. Lisa Murkowski still remains undecided on the Graham-Cassidy bill and her vote is vital to the bill’s passage.

The new draft also would allocate an additional $750 million a year to states that expanded Medicaid recently, while punishing states that expanded Medicaid when first given the option under the Affordable Care Act. The states that would most likely benefit the most from this include Montana and Cassidy’s home state of Louisiana…

…The Senate Finance Committee plans on holding the first hearing today on the bill. Congress is still waiting for the Congressional Budget Office to release its score of the bill, which would indicate how much the legislation will affect the government’s deficit.

September 25, 2017: Snopes.com posted a Fact Check titled: “Is Healthcare.gov Scheduled for Maintenance During Obamacare Enrollment?” From the Fact Check:

…In September 2017, numerous news accounts reported that the Healthcare.gov web site was scheduled to be shut down for maintenance on several occasions during the 2018 “Obamacare” health insurance open enrollment period, which runs from 1 November to 15 December 2017, prompting queries to us from readers about the issue.

Kaiser Health News, a self-described “nonprofit news service committed to in-depth coverage of health care policy and politics” reported that:

“The Trump administration plans to shut down the federal health insurance exchange for 12 hours during all but one Sunday in the upcoming open enrollment season. The shutdown will occur from 12 a.m. to 12 p.m. ET on every Sunday except Dec. 10.

The Department of Health and Human Services will also shut down the federal exchange – healthcare.gov – overnight on the first day of open enrollment, Nov. 1. More than three dozen states use that exchange for their marketplaces. HHS officials disclosed this information during a webinar with community groups that help people enroll.”…

…A spokesperson for the Center for Medicare and Medicaid Services (CMS), which runs Healthcare.gov, confirmed the maintenance schedules reported by Kaiser Health News and Sara Kliff [of Vox].

“Maintenance outages are regularly scheduled on HealthCare.gov every year during open enrollment. This year is no different. The maintenance schedule was provided in advance this year in order to accommodate requests from certified application assisters. System downtime is planned for the lowest-traffic time periods on HealthCare.gov including Sunday mornings.”

The spokesperson also said the periods set out for web site maintenance constituted the maximum anticipated amount of downtime, and averred that the actual amount of downtime might end up being less…

…The Trump administration has already cut in half the Obamacare open enrollment period, truncating the original period of 1 November 2016 to 21 January 2017 (three months) to the shorter period of 1 November to 15 December 2017 (six weeks.)…

September 26, 2017: The Hill posted an article titled: “Senate won’t vote on ObamaCare repeal bill”. It was written by Alexander Bolton. From the article:

Senate Republicans have decided not to vote on their latest ObamaCare repeal legislation, signaling a collapse in their last-ditch effort to kill off President Obama’s signature law.

“We don’t have the votes so it’s probably best we don’t do the vote,” said Sen. Steve Daines (R.-Mont.) after the GOP conference met at its regular weekly luncheon. “We’ve lost this battle, but we’re going to win the war.”

The last-ditch bill sponsored by Sens. Bill Cassidy (R.La.) and Lindsey Graham (R-S.C.) would dismantle ObamaCare’s insurance subsidy program and Medicaid expansion and covert their funding into block grants to states.

“We don’t have the votes,” Cassidy acknowledges after meeting with his colleagues on Tuesday for more than an hour.

“We made the decision since we don’t have the votes, we’re going to postpone it,” he added, expressing disappointment.

Graham said the health care debate will resume after Congress tries to move a tax reform package and expressed confidence his bill will eventually muster 50 votes…

…In the end, they couldn’t convince several of their colleagues, conservatives and centrists alike, to go along with their plan.

Sen. Susan Collins (R-Maine) delivered the final death blow on Monday, announcing she could not support the bill because of its cuts to Medicaid and its lack of protections for people with pre-existing conditions, a big issues that the late-night host Jimmy Kimmel used to criticize the bill.

Sen. Rand Paul (R-Ky.) was also a “no” vote. He said the bill would have left too much of ObamaCare in place.

Sen. John McCain (R.Ariz.) said he would be voting no on Friday, in large part because of a process he said was rushed and excluded Democrats…

…The rust on the Graham-Cassidy bill came in part because of a Sept. 30 deadline for using budgetary rules that prevented Democrats from filibustering the legislation…

September 26, 2017: Politically Georgia posted an article titled: “Georgians weary of failed Obamacare repeal but want health care action”. It was written by Ariel Hart. From the article:

For the third time, congressional Republicans admitted defeat Tuesday on a push to repeal Obamacare, seemingly for good.

In Georgia, opponents and supporters alike were weary and frustrated at the wasted time and energy that Congress has cost the nation. But they were not spent: They immediately spoke of what needs to be done now.

Providers of indigent care called for Congress to direct its attention to funding programs that expire on Saturday, such as PeachCare and hospital subsidies. A foundation that advocates for the free market called for Georgia to use existing law to implement the best parts of GOP desires…

…Several federal funding programs for hospitals, lower-income child care and other subsidies expire Saturday. To be funded, they need Congress to vote for that. U.S. Sen. Johnny Isakson has expressed a willingness now to work across the aisle on such terms….

…The problems [Dr. Karen] Kinsell and others bring up with Obamacare will also take congressional agreement but are harder: rising expenses for premiums, deductibles, and out-of-pocket costs for health care. Part of that is driven simply by the rising cost of health care.

Georgia may get a bitter taste of that this week when the state releases final agreements with health insurers on their rates for 2018. Several have indicated that uncertainty at the federal policy level is driving their prices higher.

On the state level, Georgia still has the ability to agree with the federal government on a “waiver” of certain Obamacare provisions to get more flexibility to innovate on using the money. That’s what [Kelly] McCutchen [president of the libertarian-leaning Georgia Public Policy Foundation] and some others hope will happen…

…The Georgia Hospital Association prodded Congress to remember that the state’s hospitals already absorb $1.7 billion a year in uncompensated care…

September 27, 2017: Politico posted an article titled: “Inside the life and death of Graham-Cassidy”. It was written by Jennifer Haberkorn, Burgess Everett and Seung Min Kim. From the article:

…The decision on Tuesday not to vote on the Graham-Cassidy bill marked the fourth Obamacare repeal bill failure since the summer began. But Republicans say they’re not going to stop, and [Sen. Lisa] Murkowski’s decision not to oppose the bill provided a small victory in an otherwise painful defeat.

“Today to me, it’s not a matter of if, it’s now when,” Graham said of repealing the Affordable Care Act. “Because this idea makes sense. Let’s say we fail. Let’s say we continue to fail. You’ve seen the damage done to the party, donors, people upset. The good news is I see enthusiasm for the first time among Republicans about an alternative to Obamacare.”

Graham’s positive spin comes just two weeks after he and Sen. Bill Cassidy had to publicly plead with President Donald Trump and Senate Majority Leader Mitch McConnell to get on board with a last-gasp Obamacare bill. They then went on a legislative binge, running around Washington to lobby the White House senators and conservative groups to at leas not kill their effort…

…At one point, the bill seemed to have a real chance of success. And then it ran into the same hurdles that killed every other GOP health plan. Ultimate, a number of Senate Republicans remain wary of transforming the U.S. health system in such a haphazard process – especially with plans to make deep cuts to Medicaid and roll back protections for people with pre-existing conditions.

And yet, the sudden spurt of momentum behind Graham-Cassidy, once considered a long shot, underscores how nervous Republicans are about facing voters in 2018 without fulfilling their top campaign promise or having much of a legislative record.

What hasn’t changed is that there are three hard “nos” against Obamacare repeal: Sens. John McCain of Arizona, Rand Paul of Kentucky and Susan Collins of Maine, not to mention other quietly skeptical senators…

…Both Graham and Cassidy say they merely ran out of time. Other Republicans say the effort was thwarted by bad information – early drafts had errors or misleading information – and last-minute changes that made members uncomfortable about what they’d be voting on…

…Vice President Mike Pence told Republicans on Tuesday that they need to repeal Obamacare by the end of this Congress, GOP senators said, ensuring that the Obamacare debate will be part of the 2018 mid-term elections, just like it was in every election since 2010.

But unless the Senate math shifts, Republicans are no closer to 50 votes than they were on the July evening when McCain dramatically ended the previous GOP repeal effort. And after Collins confirmed on Monday that she’s the third republican to oppose the bill, its fate was sealed…

September 27, 2017: The Intercept posted an article titled: “Lindsey Graham on Obamacare Repeal: I Had No Idea What I Was Doing”. It was written by Ryan Grim and Aida Chávez. From the article:

Senate Democrats and their progressive allies spend the last week and a half in a full-blown mobilization against an existential threat to the Affordable Care Act.

Now that it has fizzled out, the lead author of the measure, known as the Graham-Cassidy bill, has an admission to make: He had no clue what he was doing…

…But now that it’s over, the old Graham is back and more than willing to laugh at how improbable it was that a national security expert briefly held the national limelight as a supposed health policy wonk.

Graham, though, said he was not alone in his lack of understanding of health care. “Nobody in our conference believes Obamacare works. It must be replaced. But until now, we didn’t know how to do it.” Graham told reporters in the Capitol on Tuesday…

…A reporter pointed out that his ignorance at this late stage is hard to understand. “You’ve been working to overhaul this for seven years. Why is this so hard?” she asked.

“Well, I’ve been doing it for about a month. I thought everybody else knew what the hell they were taking about, but apparently not,” Graham clarified, adding he had assumed “these really smart people will figure it out.”…

…Republican leaders conceded Tuesday that they did not have the 50 votes they needed to move forward with Graham-Cassidy. Of the 52 Republicans in the Senate, John McCain of Arizona, Rand Paul of Kentucky, and Susan Collins of Maine publicly opposed the legislation, making the math easy.

Alaska Sen. Lisa Murkowski issued a statement after Graham-Cassidy was pulled from the floor, strongly implying she had also opposed the bill…

September 30, 2017: The New York Times posted an article titled: “‘Little Lobbyists’ Help Save the Health Care Law, for now”. It was written by Robert Pear. From the article:

…In the long-running battle over health care, doctors, hospitals, and insurance companies have spent millions of dollars this year. But some of the most effective advocacy has come from pint-size petitioners who spent nothing at all: children with serious medical needs who told their stories to members of Congress…

…Children like Jackson [12-years-old] and Henry [9-years-old] [both of whom have a genetic condition Noonan syndrome, which causes a bleeding disorder, short stature, and digestion problems] have put a human face on the debate over insurance regulation, premium subsidies, Medicaid expansion and cost estimates by the Congressional Budget Office.

The American Medical Association, the American Hospital Association, America’s Health Insurance Plans and dozens of other industry groups lined up against the Republican repeal bills. But, lawmakers said, what really sank the legislation was the outpouring from constituents, and few were as influential as the lobbyists who pleaded for their own lives and the lives of other children with special needs…

…The House Democratic leader, Nancy Pelosi of California, said the young lobbyists “have made all the difference in the world.” And she described the parents as formidable: “You do not want to stand in between one of these moms and the good health care of her child.”

The effort started when five families visited Senate offices in June for a day of lobbying….

October 2017: Health Affairs released an Abstract on a research article titled: “Early Medicaid Expansion Associated With Reduced Payday Borrowing In California.”

It was written by Heidi Allen, an associate professor in the School of Social Work, Columbia University in New York City; Ashley Swanson, an assistant professor of health care management and the Wharton School Senior Fellow at the Leonard Davis Institute of Health Economics, both at the University of Pennsylvania, in Philadelphia; Jialan Wang, an assistant professor of finance at the College of Business, University of Illinois at Urbana-Champaign; and Tal Gross, an assistant professor in the Department of Markets, Public Policy, and Law at Questrom School of Business, Boston University, in Massachusetts.

From the Abstract:

We examined the impact of California’s early Medicaid expansion under the Affordable Care Act on the use of payday loans, a form of high-interest borrowing used by low- and middle-income Americans. Using a data set for the period 2009-13 (roughly twenty-four months before and twenty-four months after the 2011-12 Medicaid expansion) that covered the university of payday loans from five large payday lenders with locations around the United States, we used a difference-in-difference research design to asses the effect of the expansion on payday borrowing, comparing trends in early-expansion counties in California to those in counties nationwide that did not expand early.

The early Medicaid expansion was associated with an 11 percent reduction in the number of loans taken out each month. It also reduced the number of unique borrowers each month and the amount of payday loan debt. We were unable to determine precisely how and for whom the expansion reduced payday borrowing, since to our knowledge, no data exists that directly link payday lending to insurance status. Nonetheless, our results suggest that Medicaid reduced the demand for high-interest loans and improved the financial health of American families.

October 5, 2017: The Washington Post posted an article titled: “As ACA enrollment nears, administration keeps cutting federal support of the law”. It was written by Julie Eilperin. From the article:

…Supporters of the Affordable Care Act see the president’s opposition even to changes sought by conservative states as part of a broader campaign by his administration to undermine the 2010 health-care law. In addition to trying to cut funding for the ACA, the Trump administration also is hampering state efforts to control premiums. In the case of Iowa, that involved a highly unusual intervention by the president himself.

And with the fifth enrollment season set to begin Nov. 1, advocates say the Health and Human Services Department has done more to suppress the number of people signing up than to boost it. HHS has slashed grants to groups that help consumers get insurance coverage, for example. It also has cut the enrollment period in half, reduced the advertising budget by 90 percent and announced an outage schedule that would make the HealthCare.gov website less available than last year.

The White House also has yet to commit to funding the cost-sharing reductions that help about 7 million lower-income Americans afford out-of-pocket expenses on their ACA health plans. Trump has regularly threatened to block them and, according to an administration official who was not authorized to speak publicly, officials are considering action to end the payments in November.

The uncertainty has driven premium prices much higher for 2018. A possible move by the Treasure Department to ease the requirement that most Americans obtain coverage could further erode a core element of the law…

…Trump and his aides are also looking for ways to loosen the existing law’s requirements, now that the latest congressional attempt to repeal it outright has failed. The Treasury Department may broaden the ACA’s “hardship exemption” so that taxpayers don’t face costly penalties for failing to obtain coverage, a Republican briefed on the plan said. That is sure to depress enrollment among the younger, healthier consumers whom insurers count on to help buffer the health-care costs of sicker customers…

October 10, 2017: Vox posted an article titled: “The Trump administration’s case against birth control is a stunning distortion of science”. It was written by Julia Belluz. From the article:

On Friday, the Trump Administration released long-anticipated rules that relax the Obama-era birth control mandate, which required employers to offer insurance that covered contraception for women.

Effective immediately, some companies can now more easily refuse to cover the cost of birth control by seeking religious or moral exemptions.

To justify this rollback, the administration wrote pages into the new regulations that challenge well-established research on the health impact of birth control – from whether contraceptives reduce unwanted pregnancies to the harms and benefits of the Pill.

Altogether, the case presented against birth control is a stunning distortion of the research on contraception. And it’s anything but novel…

The article continues by debunking the distortion of research on contraception presented by the Trump administration. Vox presented a series of facts in a way that is easy to understand. The Vox article provides many links to the sources of the information they present.

October 10, 2017: The Hill posted an article titled: “New York, California threaten to sue over health-care subsidies”. It was written by Rebecca Savransky. From the article:

Attorneys general from California and New York say they are prepared to sue the Trump administration to protect health care subsidies that the White House said would be cut off.

New York Attorney General Eric Schneiderman (D) said in a statement that hundreds of thousands of New York families rely on ObamaCare’s subsidies for their health care….

October 11, 2017:  California Healthline posted an article titled “California Slaps Surcharge On ACA Plans As Trump Remains Coy on Subsidies”. It was written by Chad Terhune. From the article:

California’s health exchange said Wednesday it has ordered insurers to add a surcharge to certain policies next year because the Trump administration has yet to commit to paying a key set of consumer subsidies under the Affordable Care Act.

The decision to impose a 12.4 percent surcharge on silver-level health plans in 2018 means the total premium increase for them will average nearly 25 percent, according to Covered California. Taxpayers, not consumers, will bear the brunt of the extra rate hike because federal premium assistance for policyholders, which is pegged to the cost of coverage, will also increase…

…In August, Covered California announced that 2018 premiums would rise by 12.5 percent, on average, statewide. That ticked down slightly to 12.3 percent during regulatory review. But the exchange also warned that the additional increase, averaging 12.4 percent, would be added to the silver-tier plans if President Donald Trump failed to commit to continued funding for the so-called cost-sharing subsidies that help reduce some consumers’ out-of-pocket expenses. Those payouts total about $7 billion this year nationwide.

Trump has continued paying them on a month-to-month basis while repeatedly threatening to cut them off and repeal the entire health law. He referred to the payments as “bailouts” for insurance companies…

…In Idaho, for example, the average rate for silver plans will increase 40 percent in 2018, double what the rate hike would have been had the Trump administration committed to funding the cost-sharing subsidies, according to Dean Cameron, director of the state’s Department of Insurance…

October 12, 2017: Trump signed an Executive Order titled: “Presidential Executive Order Promoting Healthcare Choice and Competition Across the United States”.  Here are a few key points from this Executive Order:

…Among the myriad areas where current regulations limit choice and competition, my Administration will prioritize three areas for improvement in the near term: association health plans (AHPs), short-term, limited-duration insurance (STLDI), and health reimbursement arrangements (HRAs).

Large employers often are able to obtain better terms on health insurance for their employees than small employers because of their larger pools of insurable individuals across which they can spread risk and administrative costs. Expanding access to AHPs can help small businesses overcome this competitive disadvantage by allowing them to group together to self-insure or purchase large group health insurance. Expanding access to AHPs will also allow more small businesses to avoid many of the PPACA’s costly requirements. Expanding access to AHPs would provide more affordable health insurance options to many Americans, including hourly wage earners, farmers, and the employees of small business and entrepreneurs that fuel economic growth.

STLDI is exempt from the onerous and expensive insurance mandates and regulations included in title I of the PPACA. This can make it an appealing and affordable alternative to government-run exchanges for many people without coverage available to them through their workplaces…

…HRSs are tax-advantaged, account-based arrangements that employers can establish for employees to give employees more flexibility and choices regarding their healthcare. Expanding the flexibility and use of HRAs would provide many Americans, including employees who work at small businesses, with more options for financing their healthcare.

My Administration will also continue to focus on promoting competition in healthcare markets and limiting excessive consolidation throughout the healthcare system…

October 12, 2017: Los Angeles Times posted an article titled: “Anthem eases up on 2018 health insurance premium hike after pressure from California”. It was written by Chad Terhune. From the article:

Insurance giant Anthem Blue Cross agreed to reduce two planned premium increases for 2018 after California regulators questioned the company’s rationale for raising rates by as much as it had initially proposed.

The scaled-back rate hikes, in the individual and small-employer markets, will reduce premiums by $114 million, state officials said…

…As a result of the department’s intervention, the nation’s second-largest health insurer shaved 3 percentage points off its 2018 rate increases for individuals and families, still leaving a hike of 3.3%. That puts the company second – after Molina Healthcare – among the 11 insurers that sell in the Covered California exchange. Anthem also cut its rate hikes on small businesses by more than half to 2.5%.

The smaller premium hikes are expected to save individuals about $21 million and small-business customers an estimated $93 million…

…Like all California insurers, Anthem had been asked by state official to submit two rate filings for the individual market. The lower set of rates assumed that the Trump administration would continue to pay so-called cost-sharing subsidies that help low-income consumers with out-of-pocket costs. The higher rate increases, which state officials adopted on Wednesday, assume President Donald Trump might make good on his threats to end those payments…

…However, the 37.3% average increase from Anthem still “poses a real concern for consumers,” especially those who do not qualify for federal tax credits that help pay for premiums, [Dena] Mendelsohn [a staff attorney for Consumers in San Francisco] said…

October 12, 2017: The Hill posted an article titled “Trump to cut off key ObamaCare payments”. It was written by Rebecca Savaransky and Nathaniel Wexiel. From the article:

President Trump will end key payments to insurers selling ObamaCare plans, the White House Announced late Thursday, marking Trump’s most aggressive move yet to dismantle the law after multiple GOP efforts to repeal and replace it failed this year.

The Trump administration has continued making the disbursements to insurers, known as cost-sharing reduction payments, on a monthly basis. But Trump had consistently threatened to end the payments, which are worth an estimated $7 billion this year…

…The payments were created as part of the Affordable Care Act but were then the subject of a lawsuit by House Republicans during the Obama administration. A federal court ruled the payments were being made illegally, but the Obama administration appealed.

Congress could still decide to appropriate the payments, and there is bipartisan agreement that they should be made. But no action has been taken, and some Republicans are hesitant to vote for what they see as a bailout of ObamaCare…

…The administration’s decision is likely to lead to lawsuits. It also puts enormous pressure on lawmakers to reach a deal on funding the payments, adding yet another partisan battle to an already full calendar…

…Cutting off the subsidies could throw the ObamaCare marketplace into chaos…

…The payments help low-income people afford co-pays, deductibles and other out-of-pocket costs associated with health insurance policies. Insurers have called the payments critical, saying that with them, they would have to massively increase premiums or exit the individual market.

Many insurers have already priced their plans for the coming open enrollment period, which begins Nov. 1…

…The decision on the payments comes after Trump on Thursday signed an executive order aimed at loosening ObamaCare restrictions on insurance plans, which could help destabilize the law.

October 12, 2017: Attorney General Eric T. Schniederman tweeted: “#BREAKING Mr. President, stop using NY families as political pawns. We’ll sure to defend #ACA subsidies.”  The tweet included a screenshot of his statement which reads:

…New York Attorney General Eric T. Schniderman released the following statement:

“Hundreds of thousands of New York families rely on the Affordable Care Act’s subsidies for their health care – and again and again, President Trump has threatened to cut off these subsidies to undermine our healthcare system and force Congress to the negotiating table. That’s unacceptable.

“I will not allow President Trump to once again use New York families as political pawns in his dangerous, partisan campaign to eviscerate the Affordable Care Act at any cost.

“This summer, the costs granted our intervention to defend these vital subsidies and the quality, affordable heath care they ensure for millions of families across the country. Our coalition of states stands ready to sue if President Trump cuts them off.”…

October 12, 2017: Attorney General of California, Xavier Becerra tweeted: “I am prepared to sue the #Trump Administration to protect #health subsidies, just as when we successfully intervened in #HousevPrice!”

October 13, 2017: The Sacramento Bee posted an editorial titled: “Trump’s latest attempt to gut Obamacare takes direct aim at 650,000 of our neighbors”. It was written by California Attorney General Xavier Becerra. From the editorial:

…Having failed to get his way in the Republican-controlled Congress, Trump Thursday night signed an especially mean-spirited executive order that seeks to revoke federal funding for what are called cost-sharing reductions.

These subsidies are paid to insurance companies under the Affordable Care Act specifically to help low-income people make co-payments for hospitalization and visits to doctors. Trump’s plan to cut payments starting on October 20 is sure to further disrupt the insurance market in some states.

In California, state officials anticipated the action, and took steps to ease its impact. Still, as many as 1.4 million Californians who earn less than $30,000 a year qualify for the subsidies. They are not individuals who can readily absorb the impact of having to pay the full cost of a doctors’ visit or hospitalization…

October 13, 2017: Donald J. Trump @realDonaldTrump tweeted: “The Democrats ObamaCare is imploding. Massive subsidy payments to their pet insurance companies has stopped. Dems should call me to fix!”

October 13, 2017: Los Angeles Times posted an article titled: “Effect of Trump’s Obamacare subsidy cuts is blunted in California – for now”. It was written by Chad Terhune, Julie Rovner, and Emily Bazar. From the article:

Unable to get Congress to “repeal and replace” the Affordable Care Act, President Trump this week took matters into his own hands.

Late Thursday evening, the White House announced it would stop paying key subsidies, known as “cost-sharing reductions”, that compensate insurers for providing discounts on deductibles, co-pays, and other out-of-pocket costs to low-income consumers.

These cost reductions are available to policyholders in the Obamacare exchanges with incomes under 250% of the federal poverty line, or about $30,000 in income a year for an individual. The subsidies, which are separate from the tax credits that help millions of people pay their premiums, have been the subject of a lawsuit that is ongoing.

The tax credits are not affected by Trump’s decision…

…Cutting off payments to insurers for the out-of-pocket discounts they provide to lower-income exchange enrollees does not mean those people will not longer get help. The law, and insurance company contracts with the federal government, require that those discounts be granted. That means insurance companies will have to figure out how to recover the money they were promised.

In many states, including California, insurers had already raised 2018 premiums by an additional amount to offset the loss of premiums in the face of earlier threats by Trump to end them…

…Californians who make too much money to qualify for the federal premium assistance and do not receive discounts on their out-of-pocket expenses for care would be hit the hardest by the surcharge. To address that, Covered California created a new silver plan that will be sold outside the exchange that won’t be subject to the surcharge…

October 13, 2017: The Federal Register (part fo the National Archives and Records Administration) posted “Religious Exemptions and Accommodations for Coverage of Certain Preventative Services Under the Affordable Care Act.”  Here are some key points:

  • The effective date of this rule was listed as 10/06/2017 – which means it went into affect BEFORE it was posted on The Federal Register, and BEFORE the public could comment on it.
  • The rule is by the Internal Revenue Service, the Employee Benefits Security Administration, and the Health and Human Services Department.
  • The rule information about this rule says: “Written comments on these interim final rules are invited and must be received by December 5, 2017.”  Right above that information, it says” These interim final rules and temporary regulations are effective on October 6, 2017. The Trump administration decided that, no matter what the content of the public comments are submitted, it would put this rule into effect BEFORE the rule was posted on the Federal Register.
  • The Summary of the rule says:

The United States has a long history of providing conscience protections in the regulation of health care for entities and individuals with objections based on religious belief and moral convictions. These interim final rules expand exemptions to protect religious beliefs for certain entities and individuals whose health plans are subject to a mandate of contraceptive coverage through guidance pursuant to the Patient Protection and Affordable Care Act. These rules to no alter the discretion of the Health Resources and Services Administration (HRSA), a component of the United States Department of Health and Human Services (HHS), to maintain guidelines requiring contraceptive coverage where no regulatory recognized objection exists. These rules also leave the “accommodation” process in place as an optional process for certain exempt entities that wish to use it voluntarily. These rules do not alter multiple other Federal programs that provide free or subsidized contraceptives for women at risk of unintended pregnancy.

The Trump administration points toward the Religious Freedom Restoration Act of 1993 (RFRA) as the reason why it is choosing to allow religious employers, who are opposed to any or all types of contraception, to refuse to provide coverage for it in the health insurance it provides to it’s female employees.

Later, the rule notes that the guidelines created by the Health Resources and Services Administration when the Affordable Care Act was being written were informed by a report from the Institute of Medicine (IOM). Here is a key paragraph from that section of the rule:

…The IOM made a number of recommendations with respect to women’s preventative services. As relevant here, the IOM recommended that the Guidelines cover the full range of Food and Drug Administration (FDA)-approved contraceptive methods, sterilization procedures, and patient education and counseling for women with reproductive capacity. Because the FDA includes the category of “contraceptives” certain drugs and devices the may not only prevent contraception (fertilization), but may also prevent the implantation of an embryo, the IOM’s recommendation included several contraceptive methods that many persons and organizations believe are aborifacient – that is, as causing early abortion – and which they conscientiously oppose for that reason distinct from whether they also oppose contraception or sterilization…

That paragraph is using incorrect information. HealthCare.gov has accurate information about what the Affordable Care Act included as covered contraceptive methods:

  • Barrier methods, like diaphragms and sponges
  • Hormonal methods, like birth control pills and vaginal rings
  • Implanted devices, like intrauterine devices (IUDs)
  • Emergency contraception, like Plan B and ella
  • Sterilization procedures
  • Patient education and counseling.

The information notes that “Plans aren’t required to cover drugs that induce abortions and services for male reproductive capacity, like vasectomies”.  The contraceptive methods listed above ARE NOT ABORTIFACIENTS. They are contraceptive methods. The Trump administration fails to understand that contraception does not cause abortion.

Medication abortion (also called the “abortion pill”) DOES cause abortion. First, a woman is given a mifepristone pill at the clinic. The woman takes a misoprostol pill about 6 to 48 hours later. Together, those two medications cause abortion. Medication abortion is NOT on the list of covered contraceptive methods.  An person may “believe” that contraception causes abortion – but that belief simply does not match the scientific and medically based facts about how contraception works.

October 14, 2017: Los Angeles Times posted an article titled: “Trump tweets that he’s ‘very proud’ of his move to end healthcare subsidies”. It was written by Lisa Mascaro. From the article:

President Trump defended his move to halt federal health insurance payments for millions of low-income Americans, even as he acknowledged rising costs faced under the Affordable Care Act.

Trump, in a series of tweets late Friday and into Saturday morning, appeared intent on deflection the outpouring concern that Americans will suffer under his executive order this week to scrap the payments…

The Los Angeles Times article included the following tweets:

October 14, 2017: Donald J. Trump @realDonaldTrump tweeted: “Health Insurance stocks, which have gone through the roof during ObamaCare years, plunged yesterday after I ended their Dems windfall!”

October 14, 2017: Donald J. Trump @realDonaldTrump tweeted: “Very proud of my Executive Order which will allow greatly expanded access and far lower costs for HealthCare. Millions of people benefit!”

…The president had wavered for months over so-called cost-sharing reduction payments, which Republicans in Congress had long targeted in their effort to dismantle Obamacare.

Under the act, the federal government pays insurers to reduce costs of policies for lower-income Americans not covered by their employers. The payments cost about $7 billion a year…

October 25, 2017: The Hill posted an article titled: “Judge won’t force Trump to keep making ObamaCare payments.” It was written by Nathaniel Weixel. From the article:

A federal court in California has struck down an emergency motion that would have forced the Trump administration to continue making ObamaCare subsidy payments to insurers.

U.S. District Judge Vince Chhabria denied the motion for an injunction, saying he was skeptical that cutting off the payments known as cost-sharing reductions (CSR) would cause an immediate injury to residents of the state.

He noted many states, including California, saw “the writing on the wall” and took actions to mitigate any potential harm if the payments were ended…

…California allowed insurers to add a surcharge to the mid-level silver plans, which increases the amount of tax credit subsidies available. So even though premiums would spike for silver plans, consumers would have other, cheaper, options.

Eighteen states and Washington D.C., signed onto the motion for a temporary restraining order that would have forced the administration to keep making the payments while a lawsuit worked its way through the courts.

Trump cut off the payments earlier this month, which are required under the law and help low-income people afford co-pays and deductibles…

November 8, 2017: The Congressional Budget Office posted a report titled: “Repealing the Individual Health Insurance Mandate: An Updated Estimate”. From the summary of the report:

The Affordable Care Act (ACA) includes a provision, generally called the individual mandate, that requires most U.S. citizens and noncitizen who lawfully reside in the country to have health insurance meeting specified standards and that imposes penalties on those without an exemption who do not comply. In response to interest from Members of Congress, CBO and the staff of the Joint Committee on Taxation (JCT) have updated their estimate of the penalty that people who have no health insurance and who are not exempt from the mandate must pay under current law…

Results of the analysis done by the Congressional Budget Office (CBO) and the Joint Committee on Taxation (JCT) about repealing the individual mandate:

  • Federal budget deficits would be reduced by about $338 billion between 2018 and 2027.
  • The number of people with health insurance would decrease by 5 million in 2019 and 13 million in 2027.
  • Nongroup insurance markets would continue to be stable in almost all areas of the country throughout the coming decade.
  • Average premiums in the non group market would increase by about 10 percent in most years of the decade (with no changes in the ages of people purchasing insurance accounted for) relative to CBO’s baseline projections.

…Those effects would occur mainly because healthier people would be less likely to obtain insurance and because, especially in the non group market, the resulting increases in premiums would cause more people to not purchase insurance…

…CBO and JCT’s estimates of this policy are inherently imprecise because the ways in which federal agencies, states, insurers, employers, individuals, doctors, hospitals, and other affected parties would respond to it are all difficult to predict. The responses by individuals in the short term to a policy that would repeal the mandate are uncertain, for example…

…CBO and JCT’s baseline projections are also uncertain, and revisions to them would alter interactions and change the estimate of the effects of eliminating the mandate. For example, if there are no payments for CSRs, premiums in the marketplaces would probably be higher than projected in the baseline. (The Administration has halted those payments, but the baseline projections used in this estimate incorporated the assumption that they would continue.) Premiums that are higher than those in the baseline projections would tend to boost the budgetary savings under this policy by increasing the estimated per-person savings from people no longer enrolling in nongroup coverage. As another example, subsidized enrollment in the marketplaces might be lower than projected in the baseline, which would tend to decrease the budgetary savings under this policy.

Despite the uncertainty, some effects of this policy are clear. For instance, the federal deficit would be many billions of dollars lower than under current law, and the number of uninsured people would be millions higher.

November 16, 2017: The House of Representatives voted on H.R 1. – Tax Cuts and Jobs Act. (More details on H.R. 1 are presented later in this blog post.)  The vote was 227 YEAS to 205 NAYS – which means that H.R. 1 passed.

Most of the Representatives who voted “YEA” were Republicans. Some Republican Representatives voted “NAY”:

  • Dan Donovan (New York District 11)
  • John Faso (New York District 19)
  • Rodney Frylinghuysen (New Jersey District 11)
  • Darrel Issa (California District 3)
  • Walter Jones (North Carolina District 3)
  • Peter T. King (New York District 2)
  • Leonard Lance (New Jersey District 7)
  • Frank A. LoBiondo (New Jersey District 2)
  • Tom McClintock (California District 4)
  • Dana Rohrabacher (California District 48)
  • Christopher H. Smith (New Jersey District 4)
  • Elise Stefanik (New York District 21)
  • Lee Zeldin (New York District 3)

Almost all of the Democrats, and both of the Independents voted “NAY”. Mark Pocan (Wisconsin District 2 – Democrat) did not vote.

November 14, 2017: The Washington Post posted an analysis titled: “Why repealing Obamacare’s individual mandate is so crucial to tax reform.” It was written by Carolyn Y. Johnson. From the analysis:

Senate Republicans slipped the repeal of a key Affordable Health Care Act provision into their tax bill Tuesday, adding a provision that would allow them to declare a victory on health care while gaining more than $300 billion to offset the cost of tax reform.

The individual mandate is one of the most unpopular parts of the ACA – a requirement that people either buy health insurance or pay a penalty. About 6.5 million taxpayers paid a fine in 2016, according to a January letter sent by IRS Commissioner John Koskien.

On one hand, repealing the mandate would be a way for Republicans to claim they are keeping their promise on unraveling President Barack Obama’s signature health-care law. But dragging a major health care provision into the tax bill provides a major second benefit: giving politicians more wiggle room on their tax plan.

The tax plan can only add $1.5 trillion to the deficit over the next decade, and Republicans are bumping up against that limit. So if they want to make more changes, they’ll probably need more money. Repealing the mandate frees up about $338 billion over a decade, according to an analysis by the nonpartisan Congressional Budget Office.

At first glance, getting rid of the penalty might appear to make tax reform harder, since the government would lose a source of income – penalty payments by uninsured people that were projected to add up to $43 billion over a decade, according to the CBO. But a repeal would bring big savings because government spending on subsidies help people afford coverage would plummet: 13 million fewer people would have health insurance in 2027…

…The move to include the provision in the tax bill was immediately opposed by major health industry groups, including the main lobbies for health insurers, hospitals and physicians. The influential groups warned in a letter to politicians that the move would drive up premiums and leave more Americans uninsured…

November 28, 2017: The Arc Blog posted information about the Tax Cuts and Jobs Act in an article titled: “Why the Tax Cuts and Jobs Act is Bad for People with Disabilities”.  From the article:

  • House of Representatives – November 16, 2017 – House passed its version of the Tax Cuts and Jobs Act.
  • Senate – Week of November 27: Senate plans to vote on its version of the Tax Cuts and Jobs Act. 51 votes are needed to pass the legislation.

…Both bills would dramatically reduce revenue that the federal government uses to pay for critical programs. As the tax revenue decreases it will likely build pressure on Medicaid, Medicare, Supplemental Security Income, and other critical programs for people with disabilities to make up for lost revenue.

The House and Senate bills reduce federal revenue by about $1.5 trillion over 10 years. Members of Congress have acknowledged that passing these tax cuts will make it easier to justify spending cuts down the road. The Congressional Budget Office (CBO) also notes that automatic spending cuts may be triggered if Congress does not act to prevent them. These automatic cuts could mean a $25 billion dollar cut to Medicare in 2018. Automatic spending cuts could also slash funds that go to states to operate critical programs such as the Vocational Rehabilitation state grant program and the Social Services Block Grant.

The Arc Blog provided a chart that makes it easy to compare the House Bill and the Senate Bill.

  • Repeal of Individual Mandate for health insurance: (Is in the Senate Bill – but not in the House bill) – CBO estimates 13+ million fewer people with health insurance and premium hikes of 10% in the insurance marketplace. The individual mandate helps ensure that enough healthy people purchase health insurance to keep insurance affordable.
  • Repeal of the medical expenses deduction: (Is in the House Bill – but not in the Senate bill) – Nearly 9 million filers claim this deduction for medical care expenses that exceed 10% of an individual’s or family’s adjusted gross income. It offsets some of the high out-of-pocket medical expenses that some people with disabilities incur, such as high cost prescription drugs, long term physical and occupational therapies, wheelchairs, prosthetics, and long term supports and services.
  • Repeal of the Disabled Access  Credit (DATC):(Is in the House Bill – but not in the Senate Bill) – The DATC assists small businesses in meeting obligations under the Americans with Disabilities Act (ADA). It allows small businesses (with less than 31 employees and gross receipts less than $1 million a year) to claim a tax credit. The credit provides 50% of eligible expenditures between $250 and $10,000 for a maximum of $5,000.
  • Repeal of the Work Opportunity Tax Credit (WOTC): (Is in the House bill – but not in the Senate bill) –  WOTC is available to employers for hiring individuals from certain target groups, including people with disabilities. The WOTC for people with disabilities provides a tax credit for up to 40% of the first $6,000 in wages, for a maximum of $2,400 for SSI beneficiaries but up to $9,600 for certain disabled veterans.
  • Reduce affordable housing production under the Low-Income Housing Tax Credit (LIHTC) program: (This is in both the House bill and the Senate bill)- LIHTC funs the creation of affordable housing across the country. Both the House and Senate bills would make changes to the LIHTC program that would reduce the number of affordable housing units produced. Changes proposed by the Senate bill are estimated to reduce units produced by roughly 300,000 over the next 10 years. The House bill has proposed even more dramatic changes estimated to reduce units produced by nearly 1 million over the next 10 years.
  • Reducing incentives for charitable deductions: (This is in both the House bill and the Senate bill.) – Raising the standard deduction could reduce the number of taxpayers who itemize deductions – including charitable deductions – from the current 30% to 5%. Combined with a decrease in the top marginal tax rate, the disincentive to itemize would reduce charitable giving by $4.9 billion to $13.1 billion annually. Many of the providers of services to people with disabilities are non profits that rely on charitable giving.
  • Repeal or limit Orphan Drugs Credit: (This is in both the House Bill and the Senate bill. The House wants to repeal it. The Senate wants to limit it.) – Businesses can receive this credit for clinical testing expenses for certain drugs for rare diseases or conditions. It is estimated that if the orphan drug credit were repealed one-third fewer drugs addressing rare diseases would be developed in the future.
  • Creation of an inadequate paid leave tax credit: (In the Senate bill – but not in the House bill.) – The Senate bill would create a two-year employer tax credit for paid family and medical leave expenses, modeled after the Strong Families Act. As structured, this tax credit is likely to primarily subsidize companies that already offer paid leave or that would have chosen to offer new or expanded paid leave benefits without a tax credit. This means that, in addition to losing revenue, the proposal would do little to reduce current gaps in access to paid leave that particularly impacts workers with disabilities and their families.

December 2, 2017: The Senate voted on H.R.1 “Tax Cuts and Jobs Act). (More details on H.R.1 are presented later in this blog post.). The vote was 51 YEAS to 49 NAYS – which means that it passed.

All 51 Republican Senators voted “YEA”. All 47 Democratic Senators, and both Independent Senators, voted “NAY”.

December 5, 2017: The Daily Beast posted an article titled: “The Trump Administration Has Done Virtually Nothing to Advertise Obamacare”. It was written by Gideon Resnick and Sam Stein. From the article:

…The official CMS Twitter account has put out two tweets total with respect to open enrollment: the first to announce that it had begin, the second to release data regarding the number of people who had signed up for plans on the exchanges.

The HHS account, meanwhile, has put out five tweets alerting followers to the ability to choose a plan. But during that same time period, the department tweeted nine times about the holidays, including instructions for how to cook a ham on Thanksgiving – “make sure it’s cooked to 145 degrees” – and a link to “creative ways to use your holiday leftovers.”…

…The actual heads of the agencies have done even less. CMS Administrator Seems Verma has not tweeted about open enrollment once since the period to sign up for Obamacare plans began on Nov. 1.

The absence of a concerted push, let alone any push at all, is another facet in a longstanding attempt by the administration to either undermine Obamacare or facilitate its demise through neglect. A lack of tweets from top officials won’t have a massive impact on the final enrollment numbers, experts say, since few potential consumes are making purchasing decisions based off what Verma or Hargan say through that particular medium.

But collectively, the refusal of Trump administration officials to promote Obamacare – from shortening the open enrollment period to six weeks (it ends Dec. 15) to massively reducing television and digital advertising to cutting budges for local outreach officials – is likely to have a major impact…

…In addition to the lack of tweets, neither Verma nor Harlan nor anyone from the Trump administration have held enrollment events for Obamacare on the day enrollment began – something their predecessors did in strategic stops across the country during past enrollment periods…

…Even communications with lawmakers has been spotty. Sen. Angus King (I-ME) has, for instance, asked Verma to delay the deadline for Maine owing to a storm that knocked out power to nearly half a million people in the state. The Senator’s office has yet to receive a formal response, a spokesperson said. Though “Senator King’s conversations with Administrator Verma have left him feeling that she was taking the request very seriously.”…

December 12, 2017: The Hill posted an article titled: “Final GOP tax bill repeals ObamaCare mandate”. It was written by Peter Sullivan. From the article:

The final Republican tax-reform bill unveiled Friday repeals ObamaCare’s individual insurance mandate, leaving the GOP poised to blow a significant hole in the health-care law next.

The change, which takes effect 2019, removes one of the least popular parts of ObamaCare, but one that many experts warn is necessary to make the law function smoothly.

Without a mandate, there is less incentive for healthy people to enroll and balance out the costs of the sick. That is expected to lead to premium increases and could lead insurers to drop out of the markets, potentially leaving some areas of the country with no coverage options at all.

Republicans say the repeal of the mandate is a form of tax relief, because it lifts a penalty on people who decide not to buy coverage.

The Congressional Budget Office estimates that repealing the mandate will increase premiums by 10 percent and cause 13 million more people to be uninsured over a decade, but that markets would remain stable in “almost all” areas of the country…

…Repeal of the mandate was already included in the Senate-passed version of the bill, and its inclusion in the final draft was expected.

The bill appears to be on track to pass both chambers next week…

December 13, 2017: The Baltimore Sun posted an article titled: “Maryland health exchange extends deadline to enroll in Obamacare”. It was written by Meredith Cohn. From the article:

Marylanders seeking health insurance under the federal Affordable Care Act will get an extra seven days to sign up, state officials plan to announce Wednesday.

The new enrollment deadline is December 22 rather than Friday.

The deadline was extended by a week to accommodate procrastinators and avoid a last-minute enrollment crush at the end of this week.

The state had adopted a shortened 45-day enrollment period set by the Trump administration for purchasing health insurance, known as Obamacare, on the federal exchange used by most states. But Maryland operates its own online marketplace for those who do not get insurance through their jobs and was free to extend the deadline…

…Trump has disparaged the health law and taken several steps to undermine it, including limiting the enrollment period, reducing advertising for the exchange, and cutting federal subsidies to insurers to limit out-of-pocket costs for low-income enrollees – a move that forced Maryland regulators to approve last-minute premium increases on top of a previous round of increases for plans being sold next year.

GOP lawmakers are also seeking to eliminate the so-called individual mandate requiring everyone to have health insurance, a measure insurers consider crucial to maintaining a large, less-risky pool of consumers…

…The week-long enrollment extension negotiated with the two carries in Maryland, CareFirst BlueCross BlueShield and Kaiser Permanente, allows more time for consumers to shop around while still allowing coverage to begin for everyone on Jan. 1…

December 14, 2017: The Hill posted an article titled: “ObamaCare expected to suffer enrollment decline as Trump cuts timeframe.” It was written by Rachel Roubein and Jessie Hellman. From the article:

Fewer people are expected to sign up for ObamaCare coverage ahead of Friday’s deadline to enroll in the exchanges.

The Trump administration’s abbreviated enrollment period has left advocates acknowledging the numbers are almost surely going to be lower than the 9.2 million who signed up on HealthCare.gov at the end of the last open enrollment season.

It’s not clear how much the numbers will drop.

ObamaCare supporters have said the sign-ups so far have been higher than they anticipated in the face of what they view as the White House’s efforts to sabotage the health-care law…

…Nearly 4.7 million people have signed up for coverage on HealthCare.gov this year as of Dec. 9, compared to the about 4 million who signed up at a similar point last enrollment season.

But there are only a few more days to add to that total, and little if any chance that the Trump administration will extend the enrollment period…

…Advocates have also hammered the administration for a 90 percent cut to ObamaCare’s advertising budget and a 41 percent funding decrease to state and local groups that help people enroll in coverage. The Trump administration has argued that the programs were ineffective, and contends that ObamaCare is a fundamentally flawed law that’s driven up premiums and limited competition.

To match last year’s HealthCare.gov enrollment of 9.2 million, 4.5 million more people would need to sign up for plans. This doesn’t include residents of 11 states and D.C. that have their own exchanges, may of which have longer enrollment periods…

…A relatively small chunk of those enrollments will come from people who signed up on HealthCare.gov last year but didn’t pick a plan this year. They’ll be automatically re-enrolled in a similar plan and [Dan] Mendelsohn [president of Avalere, a health-care consulting company in Washington D.C.] expects this will be the case for about 1.5 million people.

Sign-ups typically sure around big HealthCare.gov deadlines. Last year, enrollment increased by 2 million from Dec. 10 to Dec. 17, since consumers had to sign up by Dec. 15 to have health insurance beginning Jan.1 (the administration extended the deadline to Dec. 18 due to increased demand)…

December 14, 2017: US Weekly posted an article titled: “John McCain Hospitalized Due to Side Effects From Cancer Treatment”. It was written by Stephanie Webber. From the article:

John McCain has been hospitalized as he continues to undergo cancer treatment. He was admitted to the Walter Reed Medical Center in Washington, D.C., on Wednesday, December 13, for side effects related to his cancer therapy.

For context,  Senator John McCain (Republican – Arizona) was battling brain cancer. Obviously, this could mean he would be unable to travel to the Senate for the purpose of voting.

December 14, 2017: Reuters posted an article titled:  “Senator McCain will vote on tax bill – No. 2 Republican”. From the article:

Republican Senator John McCain, who is receiving treatment for brain cancer and has missed votes this week, will be available next week to vote on the tax compromise bill, John Cornyn, the No. 2 Republican in the U.S. Senate, said on Thursday…

December 17, 2017: GovTrack posted information about H.R.1: Tax Cuts and Jobs Act. Several changes were made to H.R. 1 before it was voted on. The information from GovTrack covers changes made by the House and changes made by the Senate.  H.R. 1 covers more than health care, but I am only including the health care related portions in this blog post.

Original Summary: 

  • The Senate version of the bill will include a repeal of the individual mandate of the Affordable Care Act. The Congressional Budget Office (CBO) estimated that doing so would increase the number of uninsured Americans by 4 million in 2019 and 13 million in 2027 but reduce federal deficits by about $399 billion over ten years.

UPDATE #2: November 27, 2017: 

  • Four months after the failed vote on a partial repeal of the ACA, Senate Republicans are taking another shot by going after the individual mandate. This could risk the votes of Sen. Susan Collins (R-ME) and John McCain (R-AZ) who voted against their party to block the previous partial repeal. Sen. Collins has criticized the provision to repeal the individual mandate. Sen. Lisa Murkowski (R-AK), who also voted against partial repeal, came out in favor of repealing the individual mandate last week.

UPDATE #3: December 5, 2017:

  • The Senate Republican tax bill passed by a vote of 51-49 Friday, 12/1/2017. Senator Bob Corker (R-TN) was the only Republican to vote against the bill, on the grounds that it “could deepen the debt burden on future generations.”
  • Monday night the House voted to go to conference committee and selected its conferees. The Senate is expected to select its conferees later this week.
  • Some of the last minute changes made to the Senate version to satisfy otherwise hesitant Republican senators were made so hastily that they were hand-written in the margins.
  • Although the bull did not include the repeal of the individual mandate, Sen. Susan Collins (R-ME) pushed to make medical expenses that reach 7.5% of gross income deductible, as opposed to the current 10%. The House bill would repeal the deduction entirely.

UPDATE 4: December 17, 2017:

  • House and Senate Republicans have come to an agreement on the tax bill, H.R. 1, which they intend to pass before Congress goes on recess on the 22nd.
  • The Affordable Care Act’s individual mandate would be repealed.
  • Reducing the threshold for medical expenses from 10% of the individual’s income to 7.5%. This was included to win the vote of Sen. Susan Collins (R-ME).  (It also included other, non-health related things, to appease other Senators.)

December 17, 2017: The New York Times posted an article titled: “McCain, in Treatment for Cancer, is Likely to Miss Senate Tax Vote”. It was written by Thomas Kaplan. From the article:

Senator John McCain, who is battling brain cancer, has returned home to Arizona and is likely to miss the Senate’s vote this week to approve a sweeping tax overhaul, though President Trump said on Sunday that the senator would return if his vote was needed.

McCain’s office said in a statement on Sunday night that the senator, who had been hospitalized recently in the Washington area, would undergo physical therapy and rehabilitation at the Mayo Clinic in Arizona and “looks forward to returning to Washington in January.”…

…The absence of Mr. McCain, a Republican, is not expected to jeopardize the passage of the tax overhaul, as party leaders won the support of two key holdouts on Friday. and had appeared on track to have the support of all 52 Republican senators. The House and Senate are expected to approve the final tax bill by midweek…

December 17, 2017: CBS News posted an article titled: “Sen. John McCain back in Arizona, will miss vote on GOP tax bill”. From the article:

Republican Sen. John McCain returned home to Arizona after spending several days in a Maryland hospital recovering from side effects from chemotherapy treatment for brain cancer, CBS News has learned. He will spend the holidays with his family and will not be on hand for the final vote on the GOP tax passage expected this week. He’s expected to return to Washington in January…

…Despite a razor-thin margin needed to pas the measure, McCain;s presence will likely not be the determining factor in the vote. Two critical senators – Bob Corker of Tennessee and Marco Rubio of Florida – announced their support for the bill last week after initially saying they would oppose earlier versions…

…McCain is not the only senator sidelined by health problems. Sen. Thad Cochran, 80, of Mississippi, had a non-melanoma lesion removed from his nose earlier this week.

A spokesman for Cochran told CBS News last week that the senator went through an outpatient procedure and “is doing well and is available for votes as needed.”

December 17, 2017: The Guardian posted an article titled: “John McCain will not vote on Republican tax cuts this week”. From the article:

John McCain will not cast his vote on the Republican tax overhaul this week, a process the No2 Senate Republican said he expected will happen on Tuesday.

Donald rumor confirmed reports the Arizona Senator has gone home to spend the holidays with his family, after spending several days in hospital in Maryland because of side effects from his treatment for glioblastoma, an aggressive form of brain cancer.

The president, who called McCain’s wife Cindy on Friday, told reporters at the White House: “I understand he’ll come if we ever needed his vote, which hopefully we won’t. But the word is John will come back if we need his vote. It’s too bad. He’s going through a very tough time, there’s no question about it. But he will come back if we need his vote.”

John Cornyn earlier told ABC’s This Week he was “confident” the Senate would pass the tax cuts “probably on Tuesday”. Without other absences or defections, McCain’s absence would not put the bill in danger. The GOP holds a 52-48 balance in the Senate, where Democrat Doug Jones has not been seated since his shock win in the Alabama election. The Republican appointee Luther Strange remains in place…

December 19, 2017: Donald J. Trump @realDonaldTrump tweeted: “The United States Senate just passed the biggest in history Tax Cut and Reform Bill. Terrible Individual Mandate (ObamaCare)Repealed. Goes to the House tomorrow morning for a final vote. If approved, there will be a News Conference at The White House at approximately 1:00 P.M.”

December 19, 2017: The House of Representatives voted again on H.R. 1 (Tax and Jobs Bill) again. (More details on H.R. 1 were provided earlier in this blog post.) This time, the vote was held “On Agreeing to the Conference Report”. This time, the vote was 227 YEAS to 203 NAYS – which means it passed.

Most of the Representatives who voted “YEA” were Republicans.  Some Republican Representatives voted “NAY”:

  • Dan Donovan (New York District 11)
  • John Faso (New York District 19)
  • Rodney Frylinghuysen (New Jersey District 11)
  • Darrel Issa (California District 3)
  • Walter Jones (North Carolina District 3)
  • Peter T. King (New York District 2)
  • Leonard Lance (New Jersey District 7)
  • Frank A. LoBiondo (New Jersey District 2)
  • Dana Rohrabacher (California District 48)
  • Christopher H. Smith (New Jersey District 4)
  • Elise Stefanik (New York District 21)
  • Lee Zeldin (New York District 3)

Most of the Democrats voted “NAY”.  Mark Pocan (Wisconsin District 2 – Democrat) did not vote. Joseph Kennedy III (Massachusetts 4th District – Democrat) did not vote.

December 19, 2017: Common Dreams posted an article titled: “Without Remorse, House GOP Passes ‘Morally Corrupt, Cruel, and Barbaric’ Tax Bill”. It was written by Jake Johnson. From the article:

…Republicans are “robbing the American people and showing no remorse,” Rep. Pramila Jayapal (D-Wash.) said in a statement on Tuesday. “This tax scam dismantles the Affordable Care Act, throwing 13 million people off their healthcare. It eliminates most of the State and Local Tax deductions, short-changing communities and resulting in as much as $152 billion in cuts to education funding over the next decade. It runs up the deficit anywhere from $1 trillion to $1.5 trillion, triggering cuts to Medicare and Medicaid. Despite what Republicans say, the fact of the matter is that 80 percent of all tax benefits in this bill go to the top one percent.”

With their decision to “rubber stamp” a tax bill that many representatives clearly haven’t read or understood, House Republicans delivered the final tax bill over to the Senate, where a vote is expected Tuesday evening. Because the House hit a “procedural snag” following its vote, it will have to vote to approve the tax measure again Wednesday morning.

While the Senate margin will likely be closer, the last-minute decision of Sen. Susan Collins (R-Maine), to back the legislation – despite having few if any of her “demands” met – dealt a blow to hopes that the GOP will fail to get the bill to President Donald Trump’s desk.

Sen. Bob Corker (R-Tenn.), who has come under fire for changing his vote to “yes” following the inclusion of a provision that could net him a $1.1 million annual tax break, has given no indication that he will vote against the measure come Tuesday…

December 20, 2017: Covered California posted an article titled: “Covered California Looks Ahead to 2019 With Continued Strong Enrollment but National Uncertainty”. Covered California is the name of California’s health insurance marketplace. From the article:

  • Consumers have until the end of Friday, Dec. 22 to sign up for health coverage that begins on Jan. 1, 2018. Covered California’s open-enrollment period runs through Jan. 31, 2018.
  • More than 220,000 new enrollees selected a plan through Dec. 15, which remains ahead of last year’s pace.
  • Based on the first month’s enrollment, most consumers are paying less for their coverage in 2018.
  • The impending removal of the individual mandate penalty, with other key actions, means significant uncertainty for 2019 – which could lead to collapsing individual markets in many states in the absence of strong federal stabilization policies.
  • Lack of federal marketing: Health insurance needs to be sold, particularly to young and healthy individuals who are less likely to feel compelled to purchase coverage on their own. The federal administration significantly reduced the marketing and outreach budget for the current open-enrollment period, which could lead to fewer consumers enrolled, a less healthy risk mix and higher premiums for consumers.
  • Recent executive order: The president’s executive order called for regulations that would allow the sale of “association health plans” or “short term plans.” Depending on how those regulations are structured, these plans could skim healthier individuals off the individual market and leave consumers without comprehensive coverage. Not only would these consumers be enrolled in “Swiss cheese” policies that were common prior to the Affordable Care Act, those left in the exchanges would see higher premiums because of a less healthy consumer pool.
  • Without federal action to offset the destabilizing effects of these issues, Covered California estimates that between 10 and 20 states could be left without any carries in their exchanges in 2019. Consumers in the remaining exchanges could also face dramatically higher premiums, particularly those who do not receive any financial assistance.

December 20, 2017: The Senate voted again on H.R. 1 (Tax and Jobs Bill). This time, the vote was “On the Motion (Motion to Recede from the Senate Amendment to H.R. 1 and Concur with Further Amendment). The purpose of this vote was to reconcile the House of Representatives version of H.R.1 with the Senate version of H.R.1.  The two needed to match.

This time, the vote was 51 YEAS to 48 NAYS.   This means the motion was agreed to.

Almost all of the Republican Senators voted “YEA”. John McCain (Republican – Arizona) did not vote. He was spending the holidays with his family after being hospitalized for several days for side effects from chemotherapy from his cancer treatment.

All of the Democratic Senators, and both of the Independent Senators, voted “NAY”.

December 20, 2017: The House of Representatives voted again on H.R. 1 (Tax and Jobs Bill).  This time, the vote was “On Motion to Concur in the Senate Amendment”.  The vote was 224 YEAS to 201 NAYS – which means it passed.

Most of the Republican Representatives voted “YEA”. Some Republican Representatives voted “NAY”:

  • Dan Donovan (New York District 11)
  • John Faso (New York District 19)
  • Rodney Frylinghuysen (New Jersey District 11)
  • Darrel Issa (California District 3)
  • Walter Jones (North Carolina District 3)
  • Peter T. King (New York District 2)
  • Leonard Lance (New Jersey District 7)
  • Frank A. LoBiondo (New Jersey District 2)
  • Dana Rohrabacher (California District 48)
  • Christopher H. Smith (New Jersey District 4)
  • Elise Stefanik (New York District 21)
  • Lee Zeldin (New York District 3)

The majority of the Democratic Senators voted “NAY”.

The following Representatives did no vote:

  • Mo Brooks (Alabama District 5 – Republican)
  • Joseph Kennedy III (Massachusetts District 4 – Democrat)
  • Grace Napolitano (California District 32 – Democrat)
  • Mark Pocan (Wisconsin District 2 – Democrat)
  • Jim Rennacci (Ohio District 16 – Republican)
  • Lamar Smith (Texas District 21 – Republican)
  • Bennie Thompson (Mississippi District 2 – Democrat)

December 21, 2017: Administrator for the Centers for Medicare & Medicaid Services (CMS) Seems Verma @SeemaCMS tweeted: “Exchange open enrollment for 2018 coverage ended w/ approx 8.8M people enrolling in coverage. Great job to the @CMSGov team for the work you did to make this the smoothest experience for consumers to date. We take pride in providing great customer service.”

December 21, 2017: The New York Times posted an article titled: “Obamacare Sign-ups at High Levels Despite Trump Saying It’s ‘Imploding'”. It was written by Robert Pear. From the article:

The Trump administration said Thursday that 8.8 million people had signed up for health insurance through the Affordable Care Act’s federal marketplace, a surprisingly large number only slightly lower than the total in the last open enrollment period, which was twice as long and heavily advertised.

The numbers essentially defied President Trump’s assertion that “Obamacare is imploding.” They suggested that consumers want and need the coverage and subsidies available under the Affordable Care Act, even though political battles over the law, President Barack Obama’s signature domestic achievement, are sure to continue in Congress and in next year’s midterm election campaigns…

…The number of people who signed up this year was 96 percent of the 9.2 million who selected health plans or were automatically re-enrolled through the federal marketplace in the last sign-up season….

…Republican efforts to dismantle the Affordable Care Act this year had an unintended effect: They heightened public awareness of the law and, according to opinion polls, galvanized support for it among consumers who feared that it might be taken away…

…But the strong demand for insurance through the Affordable Care Act could set off new efforts to dismantle the law.

The tax cut that Mr. Trump will soon sign repeals the Affordable Care Act’s tax penalties for most Americans, who go without insurance, starting in 2019. The president said Wednesday that with elimination of the individual mandate, the health law is being effectively repealed, a statement that is untrue given the law’s expansion of Medicaid, the continued guarantee of coverage for people with pre-existing conditions, and the subsidies still available to millions of people with low or moderate income…

December 25, 2017: The Washington Post posted an article titled: “Republicans knock holes in Affordable Care Act but don’t demolish the law.” It was written by Amy Goldstein. From the article:

Before Congress left Washington for the year, Republicans finally made good on their determination to knock big holes in the Affordable Care Act, crippling its requirement that most Americans carry health insurance and leaving insurers without billions of dollars in promised federal payments.

At the same time, public support for the perennially controversial law has inched up to around its highest point in a half-dozen years. Nearly 9 million people so far have signed up for ACA health plans for 2018 during a foreshortened enrollment season, far surpassing expectations…

…With recent polls showing health care remains a top concern among voters, both major political parties have an incentive to wield it as an election issue. Democrats are likely to argue that the GOP wants to take coverage away from millions of Americans, with Republicans focusing on escalating insurance prices….

…After a year of full GOP control, congressional Republicans and the White House have damaged the ACA but fallen short of their vehement goal of dismantling broad swaths of it. More ambiguous is whether their end-of-year victory – removing tax penalties starting in 2019 for people who violate the insurance mandate – will whet the GOP’s appetite for taking apart more of the law…

…Trump sought last week to equate the part of the tax legislation that undermines the individual mandate with repeal of the entire law. His assertion at a Cabinet meeting was a pronounced overstatement. Other central figures of the ACA remain intact – including its insurance marketplaces, intended for Americans who do not have access to affordable health benefits through a job; the expansion of Medicaid in more than 30 states plus the District of Columbia; and premium subsidies…

December 26, 2017: Donald J. Trump @realDonaldTrump tweeted: “Based on the fact that the very unfair and unpopular Individual Mandate has been terminated as part of our Tax Cut Bill, which essentially Repeals (over time) ObamaCare, the Democrats & Republicans will eventually come together and develop a great new HealthCare plan!”

January 5, 2018: Governor C.L. “Butch” Otter (Republican) posted a News Release on his official website. From the News Release:

Governor C.L. “Butch” Otter directed the Idaho Department of Insurance today to use flexibility provided by the Trump administration to develop guidelines under which Idaho health insurance carriers can offer coverage plans at significantly lower costs.

At the annual Associated Press Legislative Preview in the Capitol today, Governor Otter signed Executive Order 2018-02 instructing Insurance Director Dean Cameron to seek creative ways outside the restrictions of the Affordable Care Act to make health coverage more affordable for Idaho residents…

…Cameron said he hopes insurance plans from Idaho carriers can be available as early as March to reduce costs for essential health-care coverage by 30 to 50 percent. Such plans would not qualify for an Obamacare subsidy on premium payments but carries involved must agree to continue offering plans through the Your Health Idaho insurance exchange, where federal subsidies will continue to be available.

Idaho sought greater flexibility from Health and Human Services “to continue innovating and creating new products under our State law,” in a March 10, 2017 letter from Governor Otter to then-Secretary Tom Price.

President Trump also issued an executive order on January 20, 2017 – the day of his inauguration – aimed at minimizing the economic burden of the Affordable Care Act “Pending Repeal.” It stated that the federal government should “take all actions consistent with law to minimize the unwarranted economic and regulatory burdens of the Act, and prepare to afford the States more flexibility and control to create a more free and open healthcare market.”

Cameron said those steps, and elimination of the individual mandate, should enable the State to take actions to keep Idahoans from having to pay too much for insurance, resort to unconventional alternative treatments or simply go without coverage. “We believe we have the authority already,” he said. “We want to act quickly.”

January 10, 2018: Financial Times posted a very long, detailed, heartbreaking article titled: “Why are so many Americans crowdfunding their healthcare?”  It was written by Barney Jopson.  From the article:

…Then there is the issue of money. In the US, where healthcare is not a human right, any serious illness comes with a financial shock. The average cost of hospital stays for cancer patients in 2015 was $31,290, according to government figures – about half that year’s median household income. The most common form of childhood cancer costs on average $292,000 to treat, says St. Jude Children’s Research Hospital in Memphis, Tennessee.

For the most fortunate Americans, these costs are covered by comprehensive insurance plans. For millions of others, they are a potentially crippling burden. After Isabella’s diagnosis, [Claudia] Koziner [Isabella’s mother] took unpaid family leave to care for her daughter, reducing the family to a single income. She and Isabella were able to stay on the health plan provided by her employer, ensuring they did not join the 28 million Americans who lack any health insurance. Instead, they are part of a larger group that is underinsured. The family pay $15,000 each year as part of cost-sharing arrangements with the insurer, then have to cover everything it will not, ranging from protein shots to hearing tests to two-way ambulance trips that can cost up to $3,000…

…For Isabella and her parents, crowdfunding has alleviated financial pressure at an agonizing time. “The fact that at least, at this point in time, we don’t have to stress about finances is huge,” says Koziner. I don’t even know how we’d get by.” But its spread is also a symptom of a particularly American affliction: a flawed, costly healthcare system that offers some of the best care in the world to those who can afford it, while forcing millions of others to either plunge into debt or leave their illnesses untreated.

The rise of online fundraising for medical expenses brings its own troubling consequences, replicating some of the inequalities already dividing the country by forcing people to compete for funds…

…It should be no surprise that healthcare proved fertile territory [for GoFundMe]. Crowdfunding is also growing in the UK, Australia, and Canada but is generally confined to treatments not covered by public healthcare systems. In the US, it is often about paying for the basics. American medicine is big business and the US spends more on it than any other nation, yet is the only developed country that lacks universal healthcare coverage. A fifth of US household spending went on healthcare in 2013, compared with just 4 per cent in the EU, according to Eurostat, a statistics agency.

Despite this, Americans are in worse health. Judged on measures including life expectancy and infant mortality, the US ranked last for healthcare outcomes among 11 high-income countries in a study last year by the Commonwealth Fund, a New York-based research foundation…

…Crowdfunding may also perpetuate existing inequalities. Well-off people can tap into networks of well-off friends who have money to donate in a crisis. Poorer people tend to have ties to poorer people with less to give. Kenworthy and co-researcher Lauren Berliner warn that results can also be distorted by prejudicial notions of “deservingness” based on race, class and immigration status…

… No business sector, not even Wall Street, has shelled out more on lobbying than pharmaceuticals and health products. From 1998 to 2017 it spent $3.7bn influencing policymakers, according to the Center for Responsive Politics. Physicians have also preserved their generous earnings. Jobs in medicine and dentistry accounted for none of the 10 highest-paying roles in American in 2016, according to Forbes, with anesthesiologists earning an average salary of $269,000, surgeons $252,910, and family doctors $200,810…

…By the time Obama became president, voter frustration with the system’s dysfunction was such that the industry decided it had to support his push for change in order to influence it. Obamacare’s signature achievement was to reduce the number of uninsured Americans – but in doing so it cemented the primacy of private insurers…

…Half of the population have private policies provided by employers, and 7 per cent have plans purchased individually, including on Obamacare marketplaces. Government programs for the poor, elderly and veterans cover about 35 percent of the population.

Nine per cent have no health insurance, because they can’t afford it or don’t see it as a priority. According to the Commonwealth Fund, three out of 10 working-age Americans were underinsured in 2016 (meaning they had high out-of-pocket healthcare costs relative to their incomes) – 41 million people…

January 11, 2018: The Center for Medicare and Medicaid Services (CMS) sent a letter to State Medicaid Directors. From the letter:

The Centers for Medicare & Medicaid Services (CMS) is announcing a new policy designed to assist states in their efforts to improve Medicaid enrollee health and well-being through incentivizing work and community engagement among non-elderly, non-pregnant adult Medicaid beneficiaries who are eligible for Medicaid on a basis other than disability. [1] Subject to the full federal review process, CMS will support state efforts to test incentives that make participation in work or other community engagement a requirement for continued Medicaid eligibility or coverage for certain adult Medicaid beneficiaries in demonstration projects authorized under section 115 of the Social Security Act (the Act). Such programs should be designed to promote better mental, physical, and emotional health in furtherance of Medicaid program objectives. Such programs may also, separately, be designed to help individual families to rise out of poverty and attain independence, also in furtherance of Medicaid program objectives [2]…

…[1] States will have the flexibility to identify activities, other than employment, which promote health and wellness, and which will meet the state’s requirements for continued Medicaid eligibility. These activities include, but are not limited to, community service, caregiving, education, job training and substance use disorder treatment.

[2] Section 1901 of the Social Security Act authorizes appropriations to support State Medicaid programs: “For the purpose of enabling each State, as far as practicable under the current conditions in such State, to furnish (1) medical assistance on behalf of families with dependent children of aged, blind, or disabled individuals, whose income and resources are insufficient to meet the costs of necessary medical services, and (2) rehabilitation and other services to help such families and individuals to attain or retain capability for independence or self-care[.]”…

January 11, 2018: The New York Times posted an article titled: “Trump Administration Says States May Impose Work Requirements for Medicaid”. It was written by Robert Pear. From the article:

The Trump administration said on Thursday that it would allow states to impose work requirements in Medicaid, a major policy shift that moves toward fulfilling a conservative vision for one of the nation’s largest social insurance programs for low-income people.

Federal officials said they would support state efforts to require able-bodied adults to work or participate in other “community engagement activities” as a condition of eligibility for Medicaid…

…Ms. [Seema] Verma [Administrator of the federal Centers for Medicare and Medicaid Services] said the Trump administration was responding to requests from Medicaid officials in 10 states that wanted to run demonstration projects testing requirements for work or other types of community engagement like training, education, job search, volunteer activities and caregiving.

Under the new policy, Trump administration officials would allow work requirements in Medicaid somewhat similar to those already imposed in other programs like food stamps, now known as the Supplemental Nutrition Assistance Program, and the welfare program known as Temporary Assistance for Needy Families…

…The Medicaid proposals came from Arizona, Arkansas, Indiana, Kansas, Kentucky, Maine, New Hampshire, North Carolina, Utah, and Wisconsin. Several other states are considering work requirements…

…Advocates for Medicaid beneficiaries said the new policy was likely to be challenged in court if people were denied coverage for failure to meet a state’s work requirement.

Federal law gives the secretary of health and human services broad authority to grant waivers for state demonstration projects that “promote the objectives” of the Medicaid program. In the past, federal officials said that work was not among those objectives.

But Trump administration officials said on Thursday that work requirements were consistent with the goals of Medicaid, because work and work-related activities could improve the health of Medicaid beneficiaries….

…The Trump administration said that states imposing work requirement must have plans to help people meet those requirements and should help arrange job training, child care, and transportation as needed. But, it said, states cannot use federal Medicaid funds to pay for such “supportive services”…

January 11, 2018: The New York Times posted an opinion piece titled: “Trump’s Medicaid Work Requirement Will Backfire.”

It was written by Jared Bernstein (senior fellow at the Center on Budget and Policy Priorities) and Hanna Katch, (a health policy expert at the center and a former Senate health policy staff member and a California Medicaid administrator). From the opinion piece:

Just because President Trump and the Republican Congress were unable to pass health care legislation that would have unwound the coverage benefits of the Affordable Care Act doesn’t mean such attacks are behind us. To the contrary, Republicans are now making an end run around Congress to accomplish one of their harshest goals: kicking economically vulnerable people off Medicaid.

The administration’s new approach – one that no administration before it has taken – is to provide waivers to states that allow them to impose work requirements for Medicaid benefits. Thus far, the Centers for Medicare and Medicaid Services has received requests for waivers from 10 states. C.M.S. released guidance on Thursday describing how states can institute these work requirements.

Even before Thursday, C.M.S. had unilaterally changed the standards a waiver must meet to accord with Medicaid’s core mission – specifically, that whatever they do, states must increase and strengthen health coverage for people of limited means. Now the administration will be considering waivers that are likely to deprive thousands of low-income people of health care.

Some of these people will lose coverage because they can’t find jobs to fulfill the work requirements. Others will lose it because they fail to complete paperwork proving they’re working or that they qualify for exemptions. For example, people with mental illness, addiction, or chronic disease often struggle to meet bureaucratic demands; in programs that already demand that beneficiaries work, such individuals have often been punished for falling short on work requirements even though they’re supposed to qualify for exemptions…

…People losing coverage could suffer severe harm. A study of Medicaid expansion in Kentucky and Arkansas found that it led to significant gains in access to care, financial security and health, with increases in the share of low-income adults going for checkups, getting regular care for chronic conditions and reporting that they are in excellent health. It also found large decreases in the share of people struggling to pay medical bills and relying on hospital emergency rooms for care. Under the new waivers, these gains will be reversed.

It is also essential to recognize that Medicaid work requirements won’t work. There’s no evidence that Medicaid discourages work, which comports with common sense: You can’t pay rent or buy groceries with health coverage. About 80 percent of able-bodied adult Medicaid recipients are part of working families (that is, either they or their spouses work), and about 60 percent work themselves. Among adults on Medicaid who don’t work and could be subject to the work requirement, more than a third have a chronic health problem or disability, about half take care of family or go to school, and just under 10 percent can’t find work.

It’s far more likely that Medicaid work requirements will backfire, at least in terms of improving beneficiaries’ living standards. By providing coverage for workers in jobs that are unlikely to provide such benefits, and by helping to stabilize the finances of people with illnesses, Medicaid has been found to help people stay employed or find work.

Of course, not all the Republicans’ efforts to shrink Medicaid are occurring through executive, as opposed to congressional, action. The new tax law’s repeal of the Affordable Care Act’s individual mandate could, according to the nonpartisan Congressional Budget Office, cut five million from the Medicaid rolls by 2027. That’s because, absent the mandate, fewer low-income people will find out that they’re eligible for Medicaid, especially in expansion states…

January 12, 2018: Courier Journal (Part of the USA Today Network) posted an article titled: “Kentucky first to win federal approval to roll back Medicaid expansion under Obamacare”. It was written by Deborah Yetter. From the article:

Calling it an “exciting day,” Gov. Matt Bevin on Friday said federal authorities have given Kentucky broad power to reshape its Medicaid program, making it the first state in the nation to win such approval under rules that allow states to include work requirements for some recipients…

…The news was released Friday by U.S. Rep. John Yarmuth just minutes before Bevin’s announcement. Yarmuth called the move “dangerous and irresponsible,” saying it will cause tens of thousands of Kentuckians to lose health coverage.

But Bevin dismissed such comments and said the plan will transform Medicaid.

“It will be a model for the nation,” he said.

But advocacy groups disagreed, including Kentucky Voices for Health, a coalition of health organizations that had opposed the changes as unnecessary and harmful to low-income people who rely on Medicaid for health care…

…The approval comes 16 months after Bevin, a Republican elected in 2015, announced sweeping changes to the $10 billion federal-state program that provides health care for 1.4 million low-income and disabled Kentuckians, arguing it is “not sustainable”.

And it comes one day after the Centers for Medicaid and Medicare announced it has approved controversial new “community engagement” rules to allow stats to require some Medicaid beneficiaries to work or volunteer in order to get health coverage…

…The program will be phased in starting in July, officials said Friday.

Bevin’s plan would require some adults to work or volunteer at least 20 hours a week or be in school or job training to keep health benefits. He has said it will inject more personal responsibility into the government health plan and believes participants should have “some skin in the game.”…

…[Leonard] Cuello [a lawyer with the Washington-based National Health Law Program] said Medicaid law is designed purely as a health law and efforts by states to add a work requirement, as authorized by federal aid programs such as food stamps, are not allowed.

“Medicaid is a healthcare program,” he said. “It’s about health services. It’s not about employment encouragement.”…

…Advocates say the changes will cause up to 95,000 Kentuckians to lose Medicaid health coverage, according to the administration’s own calculations….

January 12, 2018: Rewire News posted an article titled: “Despite Republican Claims, Medicaid Work Requirements Would Hurt People With Disabilities”. It was written by Robyn Powell. From the article:

…Republicans have unwaveringly asserted that work requirement will only apply to people who are “able-bodied.” This claim is simply untrue. The disability exception promulgated in the new rules only covers people who receive Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI). In other words, anyone who has a disability and does not receive SSI or SSDI would likely need to adhere to the new work requirements, should their state implement them…

…To receive SSI or SSDI, a person must meet the Social Security Administration’s (SSA) stringent definition of disability: “the inability to engage in any substantial gainful activity (SGA) by reason of any medically determinable physical or mental impairment(s) which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months.” Put differently, one’s disability must be deemed so significant that they are unable to work in any type of job.

According to Rebecca Cokley, senior fellow at the Center for American Progress, “Cancer survivors, some chronic conditions, people with mental health disabilities, and those who are substance abuse survivors will likely still be impacted, as often these are folks who get Medicaid but don’t meet the qualifications for [SSI or SSDI],”

Qualifying for SSI or SSDI is no small feat and most people who endure the lengthy application process do not ultimately receive benefits. In fact, fewer than four in ten applications for SSI and SSDI are ultimately approved. Moreover, applicants often are forced to wait years and go through many appeals processes before receiving SSI or SSDI; 10,000 people died last year while waiting for their appeal to process. Nevertheless, people with disabilities “will be forced to navigate a byzantine bureaucracy to qualify [for the work requirement] exceptions,” [Ari] Ne’eman [an Obama administration appointee to the National Council on Disability] said.

January 16, 2018: Los Angeles Times posted an article titled: “Number of Americans without health insurance grows in Trump’s first year, new figures show”. It was written by Noam N. Levey. From the article:

The number of Americans without health coverage, which declined for years after passage of the Affordable Care Act, shot up in President Trump’s first year in office, according to data from a new national survey.

At the end of 2017, 12.2% of U.S. adults lacked health insurance, up from 10.9% at the end of 2016, as President Obama was completing his final term.

The increase of 1.3 percentage points, although modest, marks the first time since at least 2008 that the share of adults without insurance increased from the previous year, according to the report from Gallup, which conducts a widely followed survey asking Americans about their health coverage.

The increase indicates that 3.3 million Americans lost health coverage in 2017, Gallup concluded.

The decline in coverage was most pronounced among slices of the population on which the Obama administration and its allies had focused enrollment efforts; young adults, blacks, Latinos and households making less than $36,000 a year, Gallup found.

The losses follow years of historic insurance gains driven by the healthcare law’s expansion of coverage, which started being fully implements in 2014…

…A recent study of data from two states that have dramatically expanded coverage, Arkansas and Kentucky, found, for example, that low-income patients with chronic illnesses are now much more likely to seek recommended care.

By contrast, there has been significantly less improvement among such patients in Texas, which has not expanded coverage fully through the healthcare law.

But many Republicans, including leading Trump administration officials, have dismissed coverage gains as meaningless. They have argued that the coverage provided under the healthcare law is unaffordable – because of out-of-pocket costs are too high – or that patients face too many restrictions in their choice of doctors.

Trump came into office last January pledging to roll back the law, common called Obamacare. His administration undertook a sustained campaign throughout 2017 to discredit the law while congressional Republicans tried to repeal it.

The repeal campaign failed. But it helped weaken health insurance markets around the country, in regions that already had few insurers and higher prices than the rest of the country.

At the same time, the Trump administration dramatically cut outreach and advertising efforts…

January 19, 2018: Rewire News posted an article titled: “For People With Disabilities, Trump’s First Year Has Threatened Nearly Every Facet of Life”. It was written by Robyn Powell.  From the article:

…One of the main attacks on autonomy for people with disabilities was Republican’s fight against the Affordable Care Act (ACA), egged on by the President. Over the summer, people with disabilities, particularly members of the grassroots ADAPT, gained national attention for successfully battling the repeated attempts to repeal the ACA. Beginning with a “die-in” staged outside the office of Sen. Mitch McConnell (R-Ky.) in late June, ADAPT held dozens of direct actions – at both the U.S. Capitol and congressional offices across the country. For people with disabilities, saving the ACA was a matter of life and death.

Notably, each attempt by the GOP to repeal the ACA included significant cuts to Medicaid. This threatened not only health care for people with disabilities, but also access to necessary supports that enable us to live in our communities. Medicaid is the primary health insurer of children and adults with disabilities. It covers services that other commercial health insurance does not, such as personal care assistants (PCAs) who provide in-home care to people with disabilities. Without PCAs, some people with disabilities cannot work, go to school, or be contributing members of their community.

Last week, the Trump administration delivered another blow to health care by allowing states to impose work requirements for people who receive Medicaid. Despite the GOP’s claims, Medicaid work requirements will likely harm people with disabilities, and will result in fewer disabled people receiving Medicaid…

…In December, the GOP passed – and Trump signed into law – the Tax Cuts and Jobs Act of 2017, harking this tax reform bill a win for everyone. While this bill will leave wealthy people far better off, people with disabilities will likely face greater tax burdens and decreased opportunities to live the life they choose. The bill includes massive cuts to Medicare and other safety-net programs and eliminates tax incentives for small businesses to modify their facilities to ensure accessibility for people with disabilities. Moreover, because the law includes a repeal of the ACA’s individual mandate, health insurance premiums will undoubtedly climb, leaving them unaffordable for many – including people with disabilities…

January 22, 2018: Covered California posted information titled “Covered California Announces Continued Strong Enrollment and Reminds Consumers That Penalty Remains in Place Through 2018”. From the information:

  • The Patient Protection and Affordable Care Act’s requirements that consumers have health insurance remains in place, and consumers may face stiff tax penalties if they are not covered in 2018.
  • A recent study estimates 70 percent of consumers, who are uninsured and eligible for financial help, could purchase health insurance coverage for less than the price of the tax penalty.
  • Most consumers are paying less in monthly premiums than they did a year ago.
  • More than 342, 000 consumers have newly enrolled during the current open-enrollment period, which remains ahead of last year’s pace, and continues in California through Jan. 31.

…Covered California also reminded consumers that the Affordable Care Act’s individual shared responsibility payment, often called the individual mandate, remains in place throughout calendar year 2018. Consumers who do not have health insurance could face stiff tax penalties if they are not covered. These penalties are a minimum of $695 per adult and $347.50 per child, up to $2,085 per family, or at least 2.5 percent of annual household income – whichever is greater (for an estimated maximum penalty of $3,816 per individual and $19,080 for a family of five). The recent tax bill removes the penalty but it does not go into effect until 2019…

…A recent Covered California analysis found that the net monthly premiums for enrollees who receive financial help are on average 10 percent lower than what new and renewing consumers paid last year. The lower prices are a result of more financial help being available for consumers who qualify for assistance. The Affordable Care Act is designed to protect consumers by providing more premium tax credits when premiums rise. And for the many Californians in the individual market who do not get financial help, the robust competition has meant that for many, premium increases have been kept in the single digits…

February 9, 2018: Covered California posted information titled: “Covered California Finishes Fifth Open Enrollment Strong – New Sign-ups of 423,484 up 3 Percent Over Last Year.” From the information:

  • More than 50,000 people selected health insurance plans through Covered California in the final three days of open enrollment.
  • Covered California has now served more than 3.4 million consumers since 2014.
  • The number of renewing enrollees dropped slightly, in part due to Covered California encouraging unsubsidized Silver plan enrollees to shop off-exchange.
  • Consumers made smart choices for 2018, picking Gold plans in many cases to get the best value for themselves and their families.
  • Subsidized consumers paid less for health coverage in 2018 than 2017 due to the protective effect of their subsidy rising to offset higher premiums, while unsubsidized consumers in the individual market – both in and out of Covered California – saw their costs rise.
  • Without action by Congress, unsubsidized consumers nationwide could see their costs rise steeply in 2019 and find coverage increasingly unaffordable.

February 14, 2018: Bloomberg posted an article titled: “Ignoring Obamacare Rules, Idaho ‘Freedom’ Plans Come With Limits”. It was written by Zachary Tracer. From the article:

After Idaho’s Republican governor promised to find creative ways to get around Obamacare, one health plan in the state plans to offer skimpy coverage that may violate many of the law’s protections for patients.

Blue Cross of Idaho said Wednesday that it will offer insurance plans that don’t comply with some Affordable Care Act requirements. The “Freedom Blue” coverage is a way to give some people lower premiums upfront in exchange for less comprehensive coverage.

Others will pay more — the plans have limits on annual medical spending and will charge sicker people higher premiums or deny them coverage in some cases. Those policies are specifically forbidden by the 2010 law.

The move sets up a potential conflict with the federal government. While President Donald Trump has said he opposes the law and has taken steps to undermine it, the administration will have to decide whether to enforce legal requirements that remain on the books…

…If the department [of Health and Human Services] doesn’t act, it could be up to the courts to resolve whether Idaho is violating the law…

…In early January, Idaho Governor Butch Otter directed the state’s insurance regulator to find “creative ways” for health insurers in the state to offer more affordable coverage. Otter said the state planned to use flexibility offered by the Trump administration in an executive order, and that it had authority to do so. The insurance regulator issued guidelines for the plans later that month…

…The Idaho plan believes it’s following the flexibility it has under the law…

…The proposed plans have a $1 million annual per-person limit to how much care the insurer will pay for. The plans have many of the same general benefits as ACA plans, though one won’t cover maternity care. They can also charge more to people who are sicker after asking them extensive questions about their health.

While such policies were banned by the Affordable Care Act, Idaho plans to use the law as a backstop. If individuals end up with medical expenses that exceed the $1 million limit in the non-Obamacare plans, Idaho will require insurers to help them move into ACA plans, which don’t have limits on medical spending.

February 15, 2018: The New York Times posted an article titled: “New Health Secretary Faces First Test as Idaho Skirts Federal Law”. It was written by Robert Pear. From the article:

Alex M. Azar II, the new secretary of health and human services, said Thursday that he would closely scrutinize a plan by Idaho to allow the sale of insurance that does not comply with the Affordable Care Act, an early test of how he will enforce a law he opposes.

But he said it was too early to know what action he might take…

…Democrats in Congress, as well as the American Cancer Society and other groups representing patients, say the Idaho plan would allow insurers to discriminate against people with pre-existing medical conditions, in defiance of the federal law…

…The plan presents Mr. Azar with a choice that he could face frequently in his new job: whether to try to shore up the health law or to “let Obamacare fail,” as President Trump has threatened to do. His decisions could have significant consequences both for consumers and for Republicans in the midterm elections…

…Mr. Azar described Idaho’s plan as “a cry for help” by a state seeking more affordable coverage options for its residents. He said the Idaho program would be subject to “searching review for compliance” with federal law…

…Idaho residents will still be able to obtain coverage that complies with the Affordable Care Act on the state’s health insurance exchange, Mr. Crapo said. But Idaho will allow other options, outside the exchange.

The Republican governor of Idaho, C.L. Otter, known as Butch, issues an executive order last month to combat what he called “the overreaching, intrusive nature of Obamacare.” And on Jan. 24, the state Insurance Department issued guidelines for the sale of insurance policies that do not meed coverage requirements of the Affordable Care Act.

Idaho’s new “state-based health benefit plans” will have to carry a disclaimer: “The policy is not fully compliant with federal health insurance requirements.”

Insurers in Idaho could, in some cases, charge different rates based on a person’s health status or claims experience. In addition, insurers would not have to comply with provisions of the federal law limiting out-of-pocket costs, and they could impose caps on the dollar amount of benefits available to consumers.

Dean L. Cameron, the director of the Idaho Department of Insurance, said in an interview on Thursday that insurers could start selling the new state-based health plans as early as April…

February 20, 2018: CNN Money posted an article titled “Trump administration unveils alternative to Obamacare”. It was written by Tami Luhby. From the article:

Officials Tuesday proposed regulations that will make it easier to obtain coverage through short-term health insurance plans — which don’t have to adhere to the Affordable Care Act’s consumer protections — by allowing insurers to sell policies that last just under a year. The new rules stem from an executive order President Trump signed in October aimed at boosting competition, giving consumers more choices and lowering premiums…

…The proposal would reverse an Obama administration decision to limit the duration of short-term health plans to no more than 90 days in order to make them less attractive.

Such plans could roil the Obamacare market, drawing healthier consumers away from the exchanges and pushing up the premiums for those who remain.

Short-term health plans, which have been available for years and were originally designed to fill a temporary gap in coverage, are likely to be cheaper than Obamacare policies. But that’s because they are allowed to exclude those with pre-existing conditions and base rates on an applicant’s medical history, unlike plans sold on the Obamacare exchanges.

Also, short-term plans don’t have to offer comprehensive coverage. Typically, they don’t provide free preventative care or maternity, prescription drugs and mental health benefits. They can also impose annual or lifetime limits, meaning they may only pay out a set amount — often $1 million or less — leaving the policyholder on the hook for the rest. And, unlike Obamacare policies, they don’t have to cap consumers’ cost-sharing burden at $7,350 for 2018…

…Also, insurers aren’t required to renew the policies so those who become sick could find themselves unable to sign up again for the same plan…

…The proposed regulations are the latest step in the Trump administration’s quest to weaken Obamacare. Last month, officials unveiled a proposed rule that would make it easier for small businesses — and some self employed folks — to band together and buy health insurance. That proposal also stemmed from Trump’s executive order and is designed to broaden access to what are known as association health plans.

February 26, 2018: CNN posted an article titled: “9 million fewer Americans expected to have health insurance in 2019”. It was written by Tami Luhby. From the article:

About 9 million fewer Americans will have health insurance next year, thanks to the Trump administration and Republicans in Congress, a new report estimates.

Congress’ elimination of the individual mandate, which takes effect in 2019, and a trio of moves by President Donald Trump are expected to fuel the decrease, the Urban Institute said.

Trump’s actions include the discontinuation of federal support of a key Obamacare subsidy, the reduction of advertising and assistance for Obamacare’s open enrollment season and the proposed expansion of short-term insurance policies. The Congressional Budget Office does not consider consumers with such policies to be insured…

…The individual mandate, one of Obamacare’s least popular provisions, requires nearly all Americans to get coverage or pay a penalty. The CBO estimated in November that 4 million fewer people would be insured in 2019 because healthier people would be less likely to buy policies without the mandate in place…

…The Urban Institute estimated that the mandate’s elimination, as well as the reduced federal support of open enrollment, would leave 6.4 million fewer people with coverage by 2019…

…About 2.5 million people who would have been otherwise insured will opt for short-term policies next year instead, the Urban Institute estimates.

Combined, the elimination of the individual mandate and the expansion of short-term plans will likely cause premiums for Obamacare policies to increase an average of 18.2% next year in the 43 states that do not prohibit or limit such policies, according to the Urban Institute.

February 28, 2018: Vox posted an article titled: “20 states file a new lawsuit arguing Obamacare is illegal”. It was written by Sarah Kliff. From the article:

Twenty state attorney generals have filed a new lawsuit that – like the many lawsuits before it – aims to take down the Affordable Care Act.

The suit, filed in a Texas district court on Tuesday, makes a new legal argument that relies on Congress’s recent repeal of the individual mandate penalty…

…Let’s start with the actual argument at play here. This lawsuit starts from Congress’s recent decision to ax Obamacare’s penalty for not carrying health insurance, reducing the fine from $695 to $0 – essentially getting rid of the provision.

In previous rulings, the brief argues, the Supreme Court has stated that this mandate is crucial to making the Affordable Care Act work. The mandate gets healthy people into the insurance market, thus allowing the Affordable Care Act to also require insurers to offer coverage to those with costly pre-existing conditions, too.

With the individual mandate penalty killed, the lawsuit argues that the entire law is no longer workable and ought to be struck down…

…Or, as the lawsuit itself puts it: “Once the heart of the ACA – the individual mandate – is declared unconstitutional, the remainder of the ACA must also fall.”…

…This lawsuit is brought by 20 different states, and they no doubt decided to bring their case in a district court that they thought might be more conservative, and more sympathetic to their arguments…

The lawsuit is called “State of Texas, et. al. v United States of America, et. al.” It was filed in the United States District Court Northern District of Texas. Full text of the lawsuit can be found on the Texas Attorney General website.

Plaintifs include:

Defendants include:

  • United States of America
  • United States Department of Health and Human Services, Alex Azar, in his Official Capacity as Secretary of Health and Human Services
  • United States Internal Revenue Service and David J. Kautter, in his Official Capacity as Acting Commissioner of Internal Revenue

March 1, 2018: Health Affairs posted a survey titled “Eliminating the Individual Mandate Penalty in California: Harmful but Non-Fatal Changes In Enrollment And Premiums”. It was written by John Hsu, Vicki Funs, Michael E. Chernew, Alan M. Zaslavsky, William Dow, and Joseph P. Newhouse.

The California Health Care Foundation provided funding for the 2017 survey and data analysis. The survey was done in partnership with Covered California.  From the survey:

The federal tax reform act of December 2017 eliminated the penalty for noncompliance with the Affordable Care Act’s (ACA) individual mandate (also known as the shared responsibility requirement) starting in 2019. This legislative change has highlighted uncertainty about the penalty’s importance in inducing lower-risk individuals to purchase insurance, to purchase insurance, and the potential for higher premiums in the individual insurance market should they not do so.

The Congressional Budget Office and the Joint Committee on Taxation (CBO/JCT) estimated that within one year, eliminating the penalty would leave four million fewer individuals insured nationwide, including three million fewer with individual market insurance. Moreover, the higher risk profile of the remaining insured would drive up individual insurance market premiums by 10 percent. CBO/JCT also predicted that over time more enrollees would drop out of the insurance market, partly due to the rising premiums, resulting in five million fewer insured in 2027 compared with baseline estimates without the repeal.

Proponents of the mandate repeal suggested that the CBO/JCT methodology is flawed because it overstates the importance of the mandate for coverage. Another recent analysis suggests that the size of the mandate penalty had little effect on coverage in 2014 and 2015, but ignores any generalized “woodwork” effect of the mandate. Importantly, the effect of eliminating the penalty on market stability depends both on 1) the number of people who no longer purchase insurance, and 2) whether these people are healthier than those retaining insurance and thus have below-average medical costs. If most enrollees continue to purchase insurance, or if those who do not purchase have similar average risk to those who do purchase, there will be less impact on premiums.

From here, the survey digs into data collected in a random sample of California enrollees in the individual market. A total of 3,010 people responded who either purchased individual insurance market plans through the Covered California marketplace or outside the marketplace.

Respondents were asked whether they knew that they would have to pay a tax penalty if they did not have insurance coverage, and if so, whether they would have purchased health insurance coverage this year (2017) if there were no penalty. The survey was conducted between May and September 2017, prior to the passage of the tax reform bill.

  • 18 percent of enrollees in California’s individual market in 2017 say they would not have purchased insurance in the absence of a penalty. The substantial majority of lower-risk enrollees would still have purchased.
  • Based on this changing mix, the surveyors estimate that eliminating the mandate penalty would have caused premiums to rise 5 percent to 9 percent in California’s individual market plans.
  • Overall, 91 percent of individual market enrollees in this California sample were aware that there was a mandate penalty, and 18 percent (or almost one in five enrollees) said they would not have purchased insurance in 2017 if the penalty had not existed.
  • This reduction (about 378,000 fewer enrollees in California) is comparable to the CBO/JCT estimate of enrollment reductions nationally in the first year following the elimination of the mandate penalty, but larger than the 7 percent reported in an October 2017 nationwide Kaiser Health Tracking Poll.
  • Enrollees with the lowest levels of predicted medical spending were more likely to say they would not have purchased insurance in 2017 in the absence of the penalty, compared with those at higher levels of predicted spending.
  • For example, 30 percent and 21 percent of those in the lowest two deciles of predicted spending said they would not have purchased insurance in the absence of the penalty, compared to 13 percent and 10 percent of those in the top two deciles of predicted spending.
  • At each level of predicted spending, the majority of respondents (70 percent to 90 percent) would likely have purchased insurance in the absence of the mandate penalty.
  • Eliminating the mandate penalty could matter less in California than in other states because California has one of the most stable individual markets in the nation with a more favorable risk mix than other states, as reflected in the average risk scores published by the Center for Consumer Information & Insurance Oversight.
  • California has implemented a number of policies to reduce adverse selection into and within the market. For example, California was one of 11 states that prohibited the sale of ACA non-compliant plans in 2014, which likely improved the favorability of the individual market risk pool. It was one of five states to mandate some kind of alignment of plans sold on and off the public marketplace by requiring that all plans sold on-markeptlace have a mirrored product sold off-marketplace.
  • Relative to other states, California has invested heavily in outreach and education efforts to increase insurance uptake, outreach, and education efforts to increase insurance uptake, emphasizing reasons other than the mandate for buying insurance such as financial and health protection.

March 8, 2018: Covered California released an analysis titled: “Individual Markets Nationally Face High Premium Increases in Coming Years Absent Federal or State Action, With Wide Variation Among States”. From the Highlights of the analysis:

  • All states’ individual markets risk higher than normal premium increases – ranging from 35 to 90 percent over three years – due to continued uncertainty at the federal level, but state variation informs understanding of local risks.
  • Premium increases in the individual markets will likely range from 12 to 32 percent in 2019, and cumulative increases from 2019-2021 will range from 35 percent to more than 90 percent.
  • Increases are on average more than double the rate of medical inflation as a result of healthier consumers leaving the individual market.
  • The report identifies 17 states that are more likely – because of their historic mix and enrollment – to have cumulative premium increases of 90 percent or more and 19 additional states are at a higher risk of experiencing hikes of 50 percent.
  • Policy actions could both lower premiums and promote more plan competition by reducing uncertainty – with independent actuarial analysis finding that reinsurance or similar programs could cut premium increases in half, bringing them to single digits in many states.

The analysis has details about premium costs in a “State-by-State Interactive Mapping of Premium Increase and Instability Risk” map. It is color coded to indicate which category each state falls into:

  • Significant Marketplace Risk: These states could face a possible 35% premium increase by 2021): Washington, Oregon, California, Nevada, Utah, Colorado, Nebraska, North Dakota, South Dakota, Minnesota, Kentucky, Massachusetts, Rhode Island, and Connecticut.
  • High Marketplace Risk: These states could face a possible 50% premium increase by 2021): Montana, Idaho, Wyoming, Arizona, New Mexico, Kansas, Iowa, Missouri, Illinois, Indiana, Georgia, Florida, Virginia, Maryland, Delaware, New York, Vermont, and Maine
  • Catastrophic Marketplace Risk: These states could face a possible 90% premium increase by 2021): Texas, Oklahoma, Arizona, Louisiana, Mississippi, Alabama, Tennessee, North Carolina, South Carolina, Wisconsin, Michigan, Ohio, West Virginia, Pennsylvania, New Jersey and New Hampshire.
  • It doesn’t say why Alaska and Hawaii are not on the map, or what level of marketplace risk they face.

March 8, 2018: New York Magazine posted an article titled: “White House Tells Idaho to Sabotage Obamacare More Subtly”. It was written by Eric Levitz. From the article:

In January, Republicans in Idaho decided that if Congress wasn’t going to repeal the Affordable Care Act, they would just have to repeal it themselves. Governor C.L. “Butch” Otter signed an executive order that nullified a whole host of ACA regulations: Insurers in the Gem State would now be able to sell health-care plans that didn’t cover maternity care, mental illness, or other “essential health benefits”; to charge higher premiums to people with preexisting conditions, and deny them coverage outright if they had failed to maintain “continuous coverage”; and set a dollar limit on the amount of benefits that consumers could draw on (which is to say, a sneak provision that renders the insurance plan useless if an enrollee happens to develop an exorbitantly expensive medical condition).

The one catch was that insurers who sold such skimpy plans would be required to also sell at least one Obamacare-compliant option over the exchanges. This arrangement would allow (temporarily) healthy people to get (junky) insurance at a very cheap price – while rendering the risk pool for Obamacare-compliant plans exceptionally sickly, there by causing premiums to skyrocket for people who required comprehensive coverage.

This all constituted a flagrant violation of federal law, But responsibility for enforcing said law lay with Trump’s Health and Human Services Department, which has been flagrantly violating the spirit of Obamacare for more than a year now…

…But on Thursday night, Trump’s Health Department (somewhat apologetically) announced that it would not allow Idaho to comport itself as a sovereign nation. In a letter to Governor Otter, Seema Verma, administrator of the Centers for Medicare and Medicaid Services (CMS), wrote, “CMS is committed to working with states to give them as much flexibility as permissible under the law to provide their citizens the best possible access to healthcare. However, the Affordable Care At remains the law.”…

…Verma encouraged Idaho to try a subtler approach to nullifying Obamacare, noting that its proposal could have passed legal muster “with certain modifications.”…

April 9, 2018: Reuters posted an article titled: “Trump administration issues rule further watering down Obamacare”. From the article:

The Trump administration took additional steps to weaken Obamacare on Monday, allowing U.S. states to relax the rules on what insurers must cover and giving states more power to regulate their individual insurance markets.

The Centers for Medicare and Medicaid Services issued a final rule that allows states to select essential health benefits that must be covered by individual insurance plans sold under former President Barack Obama’s healthcare law. The 2010 Affordable Care Act requires coverage of 10 benefits, including maternity and newborn care and prescription drugs. Under the new rule, states can select from a much larger list which benefits insurers must cover.

That could lead to less generous coverage in some states, according to Avalere Health, a research and consulting firm.

President Donald Trump’s administration has used its regulatory power to undermine Obamacare after the Republican-controlled Congress last year failed to repeal and replace the law. About 20 million people have received insurance coverage through the program…

April 10, 2018: Modern Healthcare posted an article titled: “5 takeaways from CMS’ final 2019 ACA marketplace rule”. It was written by Shelby Livingston. CMS stands for Centers for Medicare & Medicaid Services. From the article:

  • The CMS allows states to determine which essential health benefits individual and small-group plans must offer, starting in 2020. States can either adopt another state’s 2017 benchmark plan; replace one or more of its benefit categories with that of another state’s; or completely build a new essential benefits package from scratch so long as the new plan is not too generous and is in line with a “typical employer plan”.
  • Plans will still have to offer the 10 essential health benefits required by the Affordable Care Act, such as maternity care or mental health care.
  • The CMS is upping the rate increase threshold that triggers a review by state regulators to premium hikes of at least 15% for 2019. The agency is also exempting student health insurance coverage from rate review requirements, effective July 1.
  • HHS (Department of Health and Human Services) is allowing “a big chunk” of Obamacare customers to drop their insurance in 2018 without having to pay an individual mandate penalty. The CMS is allowing insurance exchanges to extend exemptions to the penalty based on a lack of affordable coverage available in an area.
  • CMS will allow anyone who lived an a region with just one insurer or none at all to claim a “hardship” exemption from the penalty for as far back as 2016.
  • Those who only have access to an insurance plan that covers abortion may also get out of the penalty if they object to abortion coverage.
  • The individual mandate penalty was zeroed out starting in 2019. The new exemptions would affect all those still subject to penalty for 2018 if they don’t buy coverage.
  • The CMS went ahead with its proposal to promote innovative plan designs by eliminating standardized options from the federal marketplace in 2019. This is a major win for the health insurance industry.
  • Starting in 2019, the CMS is relaxing the rules surrounding how much of an insurer’s premium income must bet spent on medical claims and quality improvement activities, a figure known as the medical-loss ratio. Insurers covering individuals and small businesses today must spend at least 80% of their premiums on healthcare and quality improvement.
  • In 2019, states will be able to request changes to the individual market medical-loss ratio that insurers must meet if states can demonstrate that a lower medical-loss ratio would help stabilize their markets.

April 30, 2018: Journal Sentinel (Part of the USA Today Network) posted an article titled: “Wisconsin unlawfully denies necessary treatment for transgender Medicaid recipients, lawsuit claims”. It was written by Bruce Vielmetti. From the article:

Wisconsin unlawfully denies Medicaid coverage for necessary transgender medical treatments, two transgender residents claim in a federal lawsuit filed Monday.

Their doctors say Cody Flack of Green Bay and Sara Ann Makenzie of Baraboo need additional surgery to help confirm their gender identities, but the state has turned them down for coverage, which they can’t afford on their own, citing a rule that groups the treatments with tattoo removal and earlobe repair.

Though the federal Medicaid Act and state statutes say coverage should not be arbitrarily withheld based on diagnosis or condition, a Wisconsin Department of Health and Human Services regulation from 1997 cites care related to gender transition – along with tattoo removal and earlobe repair – as “medically unnecessary”…

…Wisconsin is one of 10 states that deny Medicaid coverage of treatments for gender transition, according to the lawsuit. Nineteen states explicitly cover, and the rest have no explicit policy either way.

Ever since, bureaucrats cite the rule to deny breast removal or augmentation, genital surgeries and some hormone treatment coverage for transgender Medicaid recipients, even when admitting the procedures are effective in treating gender dysphoria, the range of conditions suffered by those who identify as a gender other than the one assigned at birth.

The lawsuit, filed in federal court in Madison, contends there is no rational or legitimate basis for excluding the coverage, which denies necessary care to members of a disfavored group…

…The suit says Wisconsin’s coverage exclusion violates the Affordable Care Act, the Medicaid Act and the due process guarantee of the Fourteenth Amendment. It asks that the court enjoin enforcement of the regulation and award damages and costs to the plaintiffs…

April 30, 2018: Politico posted an article titled: “Maine governor sued for defying Medicaid expansion ballot measure”. It was written by Rachana Pradhan. From the article:

Obamacare supporters are suing Maine Gov. Paul LePage’s administration to force him to expand Medicaid, accusing the Republican of ignoring a ballot initiative that ordered the state to join the coverage program.

LePage has refused to expand Medicaid nearly six months after 59 percent of the state’s voters approved it in a first-of-its-kind ballot measure. He has insisted he won’t adopt Medicaid expansion unless state lawmakers meet his conditions for funding the program.

“With the goal of getting health care to people as soon as possible, we decided we couldn’t wait any longer,” said Robyn Merrill of Maine Equal Justice Partners, one of the advocacy groups behind the lawsuit.

The lawsuit against LePage’s administration was expected after the Maine Legislature’s recent session ended without a funding agreement. A LePage spokesperson didn’t immediately respond to a request for comment.

LePage, now in his last year in office, previously vetoed Medicaid expansion bills five times, prompting the state’s Obamacare supporters to organize the ballot initiative last year. Advocates are spearheading similar campaigns to get measures on the ballot this year in Idaho, Nebraska, and Utah…

…Roughly 80,000 low-income Maine adults are supposed to qualify for Medicaid benefits starting July 2, according to the ballot measure. The LePage administration skipped an early April deadline to formally notify the federal government it would expand Medicaid.

The lawsuit against the Maine Department of Health and Human Services was filed in state Superior Court. Other groups bringing the lawsuit include the Maine Primary Care Association and Maine Consumers for Affordable Health Care.

The office of Maine Attorney General Janet Mills, a Democrat running for governor this year, declined to comment on whether she would defend the state in the litigation…

May 2018: Urban Institute posted The Healthy America Program.

It was written by Linda J. Blumbert (an Institute fellow in the Health Policy Center at the Urban Institute. She is an expert on private health insurance (employer and nongroup), health care financing, and health system reform.

It was also written by John Holahan (an Institute fellow in the Health Policy Center, where he previously served as center director for over 30 years. His recent work focuses on health reform, the uninsured, and health expenditure growth, and on developing proposals for health systems reform.)

It was also written by Stephen Zuckerman (a senior fellow and Vice President for health policy at Urban. He has studied health economics and health policy for 30 years and is a national expert on Medicare and Medicaid payment, including how payments affect enrollee access to care and the volume of services they receive.)

Here are some key points of The Healthy America Program:

Since efforts to “repeal and replace” the Affordable Care Act (ACA) have failed, and bipartisan attempts to improve the law have stalled, some policymakers are now looking beyond incremental fixes. Here, we present a set of policy ideas that would provide universal access to comprehensive coverage but would allow people to keep their employer-sponsored coverage, would offer a range of insurer options and ensure broad pooling of health care risk, would not have an employer mandate, would provide income-related federal assistance, and would create a more flexible individual incentive to remain insured under the ACA.

The proposal builds on components of the Medicare program and the ACA Marketplaces. However, it simplifies the current health insurance system by integrating Medicaid acute care for nonelderly people and the Children’s Health Insurance Program (CHIP) – while preserving access to their benefits – with coverage for people enrolled in private nongroup insurance and people currently uninsured.

This large new Medicare-style marketplace, featuring a public plan and private insurer options, would contain costs by fostering competition among many insurers, capping provider payment rates, and addressing prescription drug pricing. This proposal is less ambitious than a single-payer system (i.e. Medicare for All), but would get close to universal coverage with much lower increases in federal spending and less disruption for people currently enrolled in employer coverage or Medicare…

  • We propose a new program called Healthy America that would be open to all non elderly Americans. It would improve income-based assistance for premiums and cost-sharing and reduce costs in less competitive areas. Like Medicare, it would offer a public plan and private insurance plans; like Medicare Advantage, its private options would benefits from caps on provider payment rates.
  • The Healthy America program would collect enrollees’ monthly payments of income-related premiums, and these payments would be reconciled with actual income through tax filings at the end of the year. People who decide to remain uninsured would lose a tax benefit, but they could reverse some of that loss by becoming and remaining insured in the following year.
  • The tax-excluding for employer-sponsored insurance would stay in place, providing the financial incentive for most workers to continue obtaining coverage through their workplace. People who choose to enroll in employer-sponsored insurance would not pay income-related premiums for Healthy America.
  • The acute care portion of Medicaid for the non elderly and CHIP would be incorporated into the Healthy America program, along with supplemental benefits (e.g., transportation; early and periodic screening, diagnostic and treatment; access to essential community providers) for low-income children and enrollees with disabilities to ensure that people eligible for Medicaid under current law would have the same benefits under the new program.
  • States would be required to continue contributing what they currently do to Medicaid and CHIP for these populations, and future state spending amounts would be indexed to a five-year rolling average of gross domestic product (GDP) growth.  Adults and children would no longer have to change insurance plans when family income changes.
  • Nonelderly people with disabilities who are eligible for Medicare could choose between enrolling in coverage with income-related assistance through the Healthy America program or obtaining their coverage through Medicare as under current law. Nonelderly people with disabilities who are ineligible for Medicare would be edible for coverage through the Healthy America program.
  • The Medicare program would remain unchanged for all people ages 65 and older and for eligible people with disabilities. The current Medicare cost-sharing structure, including different deductibles for Parts A, B, and D and no out-of-pocket limits, could be changed to match the Healthy America program.
  • All Healthy American plans would cover the ACA’s essential health benefits, along with supplemental benefits for low-income children and for enrollees with disabilities. These supplements would ensure that people eligible for Medicaid under current law would have the same benefits under the new program.

Here are some details on how premiums would work:

  • Premiums for the Healthy America plans would be income related, with federal subsidies tied to the premium associated with the benchmark 80 percent AV public plan option.
  • People with incomes below the tax-filing threshold and others with incomes below 138 percent of FPL would not be charged premiums if they enroll in a plan with premiums no higher than the benchmark plan.
  • People with incomes between 138 and 150 percent of FPL would pay premiums ranging from 0 to 2 percent of income for the benchmark plan.
  • People with incomes between 150 and 200 percent of FPL would pay premiums ranging from 2 to 4 percent of income for the benchmark plan.
  • People with incomes between 200 and 250 precent of FPL would pay premiums ranging from 4 percent to 6 percent of income for the benchmark plan.
  • People with incomes between 250 and 300 percent of FPL would pay premiums ranging from 6 to 7 percent for the benchmark plan.
  • People win incomes between 300 and 400 percent of FPL would pay premiums ranging from 7 to 8.5% of income for the benchmark plan.
  • People with higher incomes would pay premiums of no more than 8.5 percent of income for the benchmark plan.
  • At all incomes, household premium contributions for the benchmark plan would never exceed the total benchmark premium for that person or family. Premiums would be subject to modified community rating rules as under ACA, with age rating limited to a ratio of 3 to 1, as in the ACA-compliant nongroup and small-group insurance markets today.

Here are some additional details:

  • The benchmark premium would be set much like it is in the Medicare program.
  • People who remain uninsured would be responsible for paying their own medical bills and dealing directly with providers. Uninsured people and people with employer-based insurance could enroll in insurance through the Healthy America program at standard rates during the annual open enrollment period, as under the ACA.
  • Limited special enrollment periods would also be available for circumstances such as birth, adoption, and loss of employer coverage.
  • To limit adverse selection, uninsured people would lose a percentage of their standard deduction (or the equivalent for the itemized deduction) when they pay income taxes. The percentage of the standard deduction they would lose would increase with income, making the penalty progressive.
  • By design, people with incomes below the tax-filing threshold would owe no penalty because they would not own premiums.
  • People with incomes of $1 million or more would lose the entire standard deduction.
  • Most people would need to take direct action to enroll in the Healthy America program. Higher federal investment (compared with that under ACA) in outreach and enrollment assistance during open enrollment periods and throughout the year would increase awareness and lead to higher coverage rates.
  • To boost enrollment in Healthy America and increase the diversity of its health insurance risk pools, people receiving SNAP and TANF payments would be automatically enrolled. This population would be eligible for coverage with no premium in a Healthy America plan.
  • Short-term and other private insurance plans that do not comply with Healthy America regulations (consistent with the ACA’s regulatory framework) would be prohibited. Prohibited types of plans include short-term, limited-duration policies, and association health care risks.

May 1, 2018: The Washington Post posted an article titled: “Trump’s former health secretary: Americans will pay more because GOP weakened Obamacare”. It was written by Jeff Stein. From the article:

President Trump’s former top health official on Tuesday said the Republican tax law would raise the cost of health insurance for some Americans because it repealed a core provision of the Affordable Care Act.

Tom Price, Trump’s first secretary of the Department of Health and Human Services, said people buying insurance on government-run marketplaces will face higher prices because the law repealed the ACA’s individual mandate. The mandate had forced most Americans to have health coverage or face a financial penalty.

“There are many, and I’m one of them, who believes that that actually will harm the pool in the exchange market, because you’ll likely have individuals who are younger and healthier not participating in that market, and consequently that drives up the cost for other folks within that market,” Price said at the World Health Care Conference in Washington…

…”Those effects would occur mainly because healthier people would be less likely to obtain insurance and because, especially in the nongroup market, the resulting increases in premiums would case more people to not purchase insurance, the CBO [Congressional Budget Office] said at the time. [in November of 2017]…

May 4, 2018: MedPage Today posted an article titled: “ACP, ACOG Fear Return of ‘Domestic Gag Rule'”. It was written by Molly Walker. From the article:

Citing “something imminent” from the Trump administration in relation to Title X funding, the American College of Physicians (ACP) and the American College of Obstetricians and Gynecologists (ACOG) reiterated their concern about any changes to these programs.

While it is unclear if these changes will come in the form of an executive order or more formal rulemaking, the organizations are warning of a potential Reagan-era “domestic gag rule” that forbade providers receiving Title X funding from discussing or making referrals for abortion. The rule also mandated financial and physical separation of Title X-funded programs from activities related to abortion. It was reminded in 1993 by President Clinton.

In addition to reproductive healthcare, Title X clinics also provide preventative services, such as gynecology exams, for primarily low-income individuals.

Officials at ACOG and ACP, which represent more than 200,000 physicians nationwide, stressed that they haven’t seen the final action so they “don’t know yet what it’s going to do”. But they believe the current administration is planning to change eligibility requirements for providers and healthcare centers to receive Title X funding, inhibiting them from offering women the fullest range of preventative reproductive health services available. The officials characterized the anticipated regulations as “turning back the clock” on women’s healthcare.

“We are deeply concerned about anticipated changes to Title X, which move away from science-based principles and erode standard of care by interfering in the patient/provider relationship,” said Hal Lawrence, MD, ACOG executive vice president and CEO. “We don’t need the government interfering in the exam room, and the government should not be interfering in what women can know and what kind of options she should be given.”

He further characterized the idea of not being able to go in and discuss “something that is available” with a patient as “against the ethics of the practice of medicine.”

Shari Erickson, ACP’s Vice President for governmental affairs and medical practice, described any such changes to Title X as “out of date and out of touch” and that they have the potential to impact “millions of individuals,” especially women seeking access to contraception, reproductive healthcare and preventative services.

“We are strongly opposed to changes that restrict federal funding for physicians and healthcare professionals,” she added…

May 8, 2017: President Trump signed a Special Message to the Congress of the United States. It said:

In accordance with section 1012 of the Congressional Budget and Impoundment Control Act of 1974 (2 U.S.C. 683), I herewith report 38 rescissions of budget authority, totaling $15.4 billion.

The proposed rescissions affect programs of the Departments of Agriculture, Commerce, Energy, Health and Human Services, Housing and Urban Development, Justice, Labor, State, Transportation, and the Treasury, as well as the Corporation for National and Community Service, Environmental Protection Agency, Railroad Retirement Board, the Millennium Challenge Corporation, and the United States Agency for International Development.

The details of these rescissions are set forth in the enclosed letter from the Director of the Office of Management and Budget.

The letter from the Director of the Office of Management and Budget is long and very detailed.  Here are the parts that relate to health care:

  • Rural Community Facilities Program Account – $2,000,000 proposed for rescission. The community facilities grants provide assistance to low income rural communities for essential community facilities such as police stations and medical clinics. The FY 2018 appropriations fully funded the program, and these balances are not needed to carry out the program in FY 2018.
  • Children’s Health Insurance Fund – $5,149,512,000 proposed for rescission. The proposal would rescind $5.1 billion in amounts made available by the Medicare Access and CHIP Reauthorization Act of 2015 to supplement the 2017 national allotments to States, including the $3.1 billion in unobligated balances available on October 1, 2017, and $2 billion in recoveries as of May 7, 2018. The 2017 one-time appropriation was made available in addition to the annual Children’s Health Insurance Program (CHIP) appropriation to reimburse states for eligible CHIP expenses. Authority to obligate these funds to states expired on September 30, 2017, and the remaining funding is no longer needed. Enacting the rescission would have no programmatic impact. The proposed recession would have no effect on outlays.
  • Center for Medicare and Medicaid Innovation – $800,000,000 proposed for rescission. This proposal would rescind $800 million in amounts made available under Public Law 111-148 for FYs 2011 to 2019 for the Center for Medicare and Medicaid Innovation (the Innovation Center) of which there were $3.5 billion available on October 1, 2017. The Innovation Center was created to test innovative payment and service delivery models to reduce program expenditures under Medicare, Medicaid, and CHIP while preserving or enhancing quality of care. These funds are in excess of amounts needed to carry out the Innovation Center’s planned activities in FYs 2018 and 2019, and the Innovation Center will receive a new mandatory appropriation in FY 2020. Enacting the rescission would also the Innovation Center to continue its current activity, initiate new activity, and continue to pay for its administrative costs.
  • Child Enrollment Contingency Fund – $1,865,000,000 proposed for rescission. This proposal would rescind $1.9 billion in amounts available for the Children’s Health Insurance Program Contingency Fund, of which there were $2.4 billion available as of March 23, 2018. The Contingency Fund provides payments to States that experience funding shortfalls due to higher than expected enrollment. At this time, Centers for Medicare and Medicaid Services does not expect that any State would require a Contingency Fund payment in FY 2018; therefore, this funding is not needed. Enacting this rescission would have no programmatic impact. The proposed rescission would have no effect on outlays.
  • International Disaster Assistance – $252,000,000 proposed for rescission. This proposal would rescind $252 million in prior year balances of emergency funding appropriated in FY 2015 for the Ebola response, of which there were $470 million in emergency balances available for the Ebola respond on October 1, 2017. The Congress provided these for countries affected by, or at risk of being affected by, the Ebola virus disease outbreak in 2015. These funds remain from the initial outbreak in 2015, and are no longer needed because the Ebola response has largely concluded. Enacting the rescission would therefore not impact the Ebola response.

May 8, 2017: The Congressional Budget Office posted a Cost Estimate titled: “Proposed Rescissions for the Children’s Health Insurance Program”. From the Cost Estimate:

The proposals would rescind approximately $7 billion. Of this, $5.1 billion would be rescinded from the unobligated balances made available by section 301(b)(3) of Public Law 114-10, and $1.9 billion would be rescinded from amounts made available for fiscal year 2018 under the Child Enrollment Contingency Fund, section 2104(n)(2) of the Social Security Act.

CBO was asked for its assessment of the proposed rescissions’ effect on federal spending and insurance coverage. Authority to distribute the funds to states made available under 301(b)(3) expired in 2017. In addition, based on information from the Centers for Medicare and Medicaid Services, CBO projects the the rescission from the Child Enrollment Contingency Fund would not affect payments to states over the 2018-2028 period. For these reasons, CBO estimates that rescinding the unobligated balances would budget authority by $7 billion, but would not affect outlays, or the number of individuals with insurance coverage.

May 9, 2018: The Congressional Budget Office posted a Cost Estimate titled: “H.R. 3, Spending Cuts to Expired and Unnecessary Programs Act.” From the Cost Estimate:

H.R. 3 would rescind budget authority that was proposed to be rescinded in special messages transmitted to the Congress by the President on May 8, 2018, pursuant to Title X of the Impoundment Control Act of 1974.

Assuming enactment by the end of June 2018, CBO estimates that the provisions of H.R. 3 would reduce budget authority by approximately $15 billion and outlays by $1 billion over the 2018-2028 period. Further, CBO estimates that the combined budgetary effects of the President’s proposals would be the same as the contents of H.R. 3.

Outlay savings would be significantly lower that the amount of budget authority reminded for two reasons. First, many of the amounts proposed for recession have remained unspent by agencies for years; CBO reviewed the historical spending patterns of the affected accounts and concluded that most of the funding would not be spend under current law. Second, the administration has indicated that these proposals are aimed at reducing funding that is no longer necessary for agencies to fulfill the purposes for which it was originally appropriated by the Congress. In a letter from the Office of Management and Budget accompanying the President’s special messages, the Administration estimates that those proposals would reduce outlays by $3 billion…

May 11, 2018: The White House posted “President Donald J. Trump’s Blueprint To Lower Drug Prices”. From the Blueprint:

…President Donald J. Trump’s blueprint includes new actions and proposals to drive down drug prices for all Americans.

  • President Trump’s blueprint will seek to encourage innovation, while also promoting better price competition and addressing foreign freeloading.
  • The Department of Health and Human Services (HHS) will:
  • Take steps to end the gaming of regulatory and patent processes by drug makers to unfairly protect monopolies.
  • Advance biosimilars and generics to boost price competition.
  • Evaluate the inclusion of prices in drug makers’ ads to enhance price competition.
  • Streamline and accelerate the approval for over-the-counter drugs.
  • Speed access to and lower the cost of new drugs by clarifying policies for sharing information between insurers and drug makers.
  • Avoid excessive pricing by relying more on value-based pricing by expanding outcome-based payments in Medicare and Medicaid.
  • Work to give Part D plan sponsors more negotiation power with drug makers.
  • Examine which Medicare Part B drugs could be negotiated for a lower price by Part D plans, and improving the design of the Part B Competitive Acquisition Program.
  • Update Medicare’s drug-pricing dashboard to increase transparency.
  • Prohibit Part D contracts that include “gag rules” that prevent pharmacists from informing patients when they could pay less out-of-pocket by not using insurance.
  • Require that Part D plan members be provided with an annual statement of plan payments, out-of-pocket spending, and drug price increases.
  • Work across the Administration to address intellectual property theft and foreign freeloading…
  • ..The U.S. Trade Representative will prioritize addressing unfair intellectual property and market access policies in our trade agreements, so that partners contribute their fair share to innovation.
  • The Administration will publish a comparison of drug prices in the United States with those in other OECD countries, to examine freeloading…

The next part provides the following information on “Budge Proposals to Lower Drug Prices”:

  • President Trump has proposed reforms to the Medicare Part D program, including:
  • Allowing greater flexibility in benefit design to encourage better price negotiation.
  • Offering free generics to low-income seniors.
  • Requiring plans to share a minimum portion of drug rebates with patients.
  • Discouraging plans from accelerating beneficiaries into catastrophic phase of the benefit with costly brand name drugs.
  • Protecting seniors from catastrophic costs through a new out-of-pocket maximum, while ensuring plans are incentivized to limit excessive costs.
  • Medicaid Part B reforms proposed by the President would limit payment for price increases that are above the inflation rate and cut incentives for doctors to write high-price prescriptions.
  • Reforms would ensure hospitals paid under Medicare Part B that provide more than one precent of their patient costs in charity care could retain a discount under the 340B program.
  • The President has proposed actions to maximize competition and innovation, including curbing abuse of FDA safety rules an the 180-day “first-to-file” exclusivity clock…

May 12, 2018: President Trump released a statement titled: “Presidential Message on National Women’s Health Week”. From the statement:

This Sunday marks the beginning of National Women’s Health Week. This is an opportunity to honor the importance of women across America and renew our pledge to support their health and wellbeing.

Women are integral members of our families and communities who can face unique healthcare challenges. Whether breast cancer, heart disease, or Alzheimer’s, my Administration is committed to continue addressing women’s health through advancements in medical research, rapid reviews and approvals of new safe and effective therapies, and affordable treatments and care options.

The ongoing opioid crisis is of particular concern for women. On average, 115 Americans die each day from opioid-related overdoses – a faster that has contributed to the decrease in life expectancy over the past two years. The crisis has hit women particularly hard in part because they are more likely to suffer from chronic pain conditions for which opioids are often prescribed….

…The Department of Health and Human Services (HHS) has developed a comprehensive strategy to combat the opioid epidemic and enhance non-addictive pain treatments by working with medical experts, policymakers, community groups, and families who have experienced the tragedy of opioid addiction. Through these partnerships, the HHS Office of Women’s Health has awarded 20 grants to public and private organizations that are on the frontlines of the opioid crisis.

The Substance Abuse and Mental Health Services Administration has also published guidance for treating pregnant women and new mothers with opioid use disorder, a critical resource for the Nation’s hardworking medical professionals. It is vital for the wellbeing of our Nation that we support those who are suffering from drug addictions as well as all expecting and postpartum mothers. Similarly, the National Institutes of Health is engaging in research regarding interventions to help both the mothers and infants born to women with opioid use disorder.

…Through robust tax reform, we championed a doubled Child Tax Credit to ensure parents can adequately support their children. We are also focused on expanding access to paid family leave benefits for new mothers and fathers. The new reality is that in more than 60% of the homes of American married couples with children, both parents work…. Recent research suggests that women’s labor force participation has stalled due to the lack of family-friendly policies, including paid leave….Additionally, I signed an Executive Order to expand access to sports, fitness, and nutrition, with a specific focus on helping girls from economically challenged communities live act and healthy lifestyles…

May 14, 2018: 45 United States Senators sent a letter to Alex M. Azar II, Secretary of the U.S. Department of Health and Human Services. From the letter:

We are writing today in support of the Title X family planning program (Title X) and to express our strong opposition to any changes to Title X that would restrict access to affordable, high-quality and lifesaving reproductive healthcare in communities across the country.

Title X is the nation’s only federal program dedicated to providing family planning services to low-income and otherwise underserved individuals. Each year, roughly four million women, men, and adolescents rely on Title X-funded health centers for basic preventative health care, including cancer screenings, birth control, sexually transmitted infection (STI) screenings, pregnancy testing, and well-woman exams. Nearly two-thirds of Title X patients have incomes at or below the federal poverty level, and 43% of patients are uninsured. In 2016, nearly 4,000 Title X funded health centers performed 720,000 Pap tests, provided nearly one million women with breast exams, and administered 1.2 million HIV tests. Title X providers offer confidential, medically accurate, and evidence-based care, ensuring that patients relieve the highest standard of medical care.

In addition to providing care to low-income, uninsured, and underinsured individuals, Title X yeilds critical cost savings to the American healthcare system. Every dollar invested in Title X saves more than seven dollars in Medicaid-related costs. By helping individuals obtain the preventative services they need, Title X advances the health and well-being of individuals, families, and our nation as a whole while saving taxpayer dollars in the process.

In keeping with longstanding legal, ethical, and medical standards of healthcare, Title X providers offer patients medically accurate counseling on and referrals for all pregnancy options – including parenting, adoption, and abortion. The Title X program has never funded abortion services at its health centers. Health centers that receive Title X to provide family planning care may also separately provide abortions using non-federal funds.

In spite of the critical role that Title X-funded health centers play in promoting the health and wellbeing of millions of people, President Trump may seek to dramatically reduce the reach of Title X by reinstating the “domestic gag rule,” which was first issued under the Reagan administration but was never fully implemented. This “gag rule” would bar patients from receiving information to support their ability to make informed decisions about their own reproductive health. This means that the millions of patients who obtain care at Title X-funded health centers annually would be denied the ability to receive complete and accurate information about their medical options, including counseling on, and referrals, for abortion. On top of the ban on counseling and referrals, the “gag rule” would impose additional requirements intended to bar providers from participating in Title X that also separately provide abortion services.

Calls to reinstate these policies directly acknowledge this effort as an opportunity for President Trump to fulfill his pledge to “defund Planned Parenthood,” whose health centers remain an essential part of the family planning safety net, serving 40 percent of Title X patients. In reality, other providers of Title X-funded care would face immense challenges in attempting to absorb the patients that would lose access to care if Planned Parenthood were eliminated as a Title-X funded provider. According to recent analyses, other Title-X funded providers would have to expand their contraceptive caseloads by an average of 70 percent just to maintain access to contraceptive care at current levels.

A “domestic gag rule” would have a devastating impact on the overall Title X network and the millions of individuals who rely on it for care. This move would disproportionately impact communities of color, the uninsured, and low-income individuals, and it could reverse progress made in critical areas. For example, unintended pregnancy rates in the U.S. – including those among teenagers – have been declining. We cannot threaten to reverse this progress by crippling Title X: in 2015 alone, the contraceptive services supported by Title X helped women to avoid 822,000 unintended pregnancies, which would have resulted in 387,000 unplanned births to 278,000 abortions.

We strongly oppose efforts to undermine the integrity of the Title X program and harm the millions of people who rely on it for care. Federal health policy should be evidence-based and produced with the best interests of patients in mind.

May 15, 2018: 169 members of the United States House of Representatives sent a letter to Alex M. Azar II, Secretary of the U.S. Department of Health & Human Services. From the letter:

We would like to express our support of the Title X family planning program and our strong opposition to any plans to reinstate the “domestic gag rule,” which imposes restrictions on Title X providers and restricts access to affordable, quality, and lifesaving health care in communities across the country.

As you know, Title X is the only federal grant program dedicated to providing family planning services to low-income and otherwise underserved individuals. Each year, Title X offers roughly four million women and men confidential, medically accurate, and evidence-based care. With services ranging from cancer screenings to well-woman exams, Title X providers ensure their patients receive the highest standard of medical care. As every federal dollar invested in Title X saves Medicaid more than seven dollars, this is also a program that taxpayers can – and do – believe in.

In keeping with longstanding legal, ethical, and medical standards of health care, Title X providers offer patients medically accurate counseling on and referrals for all pregnancy options – including parenting, adoption and abortion. The Title X program has never funded abortion services at its health centers, and health centers that receive Title X funds to provide family planning care may also separately provide abortions using non-federal funds.

In spite of the critical role that Title X plays in promoting the health and well-being of millions of people, President Trump has indicated he plans to dramatically reduce its reach by reinstating the “domestic gag rule.” This rule would prevent health care providers from receiving Title X funding if they even mention aboriton or abortion-related services to their patients. The domestic gag rule would effectively restrict the ability of patients to receive medical counseling on abortion and make informed decisions about their own reproductive health. On top of the ban on counseling and referrals, the ‘gag rule’ would impose additional requirements intended to bar providers from participating in Title X that also separately provide abortion services. This would have a devastating effect on the millions of Americans who rely on Title X for basic health needs, and it would have a disproportionate impact on low-income individuals and communities of color.

Reinstating the domestic gag rule is nothing more than an opportunity for President Trump to fulfill his pledge to “defund Planned Parenthood,” whose health centers serve 40 percent of Title X patients and remain an essential part of the family planning safety net. Additionally, other providers of Title X-funded care would face immense challenges in attempting to absorb the patients that would lose access to care through Planned Parenthood.

Finally, a “domestic gag rule” could revers progress made in critical areas. Primarily, unintended pregnancy rates in the U.S. – including those among teenagers – have been declining. In 2015 alone, the contraceptive services supported by Title X helped women avoid 822,000 unintended pregnancies, which would have resulted in 387,000 unplanned births and 278,000 abortions. Cutting access to eligible providers would only pare back access to contraceptive services.

We strongly support efforts to undermine the integrity of the Title X program and harm the millions of people who rely on it for care. Federal health policy should be evidence-based and produced with the best interests of patients in mind. It should not be the result of the political whims of a partisan campaign pledge.

May 16, 2018: The Hill posted an article titled: “Graham working on new ObamaCare repeal bill”. It was written by Peter Sullivan. From the article:

Sen. Lindsey Graham (R-S.C.) said Wednesday he is working on a new version of his ObamaCare repeal-and-replace bill and has not given up on efforts to do away with the law despite Republicans’ failure last year…

…The effort appears to have little, if any, chance of passing this year. Republican leadership has made clear that it has moved on from the ObamaCare repeal effort, and the GOP has an even slimmer margin in the Senate than they did last year when they failed to win enough votes for a bill.

The new bill would keep the core element of last year’s bill from Graham and Sen. Bill Cassidy (R-La.), which is repealing ObamaCare’s subsides and Medicaid expansion and giving that money to the states in a block grant…

…Graham said Wednesday that he has been talking to other senators about his effort. “We’re talking to everybody,” he said.

Graham’s effort is working in parallel with an effort from conservative groups like the Heritage Foundation and the Galen Institute, which are working with former Sen. Rick Santorum (R-Pa.) and other groups on a new ObamaCare replacement plan.

The White House told The Hill earlier this month that it “fully supports” the effort, and White House staff have been attending meetings on the plan at the Heritage Foundation…

May 16, 2018: The Hill posted an article titled: “Trump expected to cut Planned Parenthood funding through regs”. It was written by Jessie Hellmann. From the article:

The Trump administration may take action to cut federal funding to Planned Parenthood as a result of pressure from congressional Republicans and anti-abortion lobbyists.

Opponents of abortion have launched an all-out campaign urging the administration to bring back Reagan-era abortion restrictions on federal family planning dollars that would target Planned Parenthood.

The regulations would ban organizations that receive family planning dollars under the Title X Family Planning Program, which funds organizations providing services like birth control to low-income women and men, from promoting abortion or referring patients for abortions. Former President Reagan first issues the regulations, which Democrats describe as a “domestic gag rule”, in 1988. They also require a physical separation of Title X funding recipients from abortion providers.

Republicans see the action as a way to movie the GOP base ahead of the midterm elections, where the party’s majorities in the House and Senate are in play…

…Due to a lengthy legal battle, the regulations were never fully implemented but were upheld by the Supreme Court after Reagan left office.

But with a Republican president who has promised to defund Planned Parenthood, now is the perfect time to restore the regulations, abortion opponents say…

…While federal law prohibits the use of federal funding for abortions in most cases, abortion opponents and Republicans have long argued money that goes to Planned Parenthood still indirectly supports the procedure.

Anti-abortion advocates have been frustrated over the GOP Congress’s failure to defund Planned Parenthood. The GOP’s slim majority in the Senate has been the obstacle.

Frustration swelled when Congress passed a spending bill earlier this year that excluded a measure defunding Planned Parenthood, a result negotiated between Democrats and Republicans to avoid a government shutdown…

May 16, 2018: Pacific Standard posted an article titled: “Transparency Advocates Log the Disappearance of Obamacare Information from Government Websites.” The article was written by Francie Diep. From the article:

Though the Affordable Care Act remains in effect, various mentions of it have disappeared from .gov webpages.

The only webpage on Medicare.gov that was dedicated to describing how the Affordable Care Act affects Medicare was quietly taken down last year, a government transparency group has found.

Before December of 2017, visitors to Medicare.gov could navigate to a page called “The Affordable Care Act & Medicare” from the website’s “About Us” section. The page told Medicare enrollees whether the passage of the Affordable Care Act – commonly known as Obamacare – meant the had to sign up for new plans. (It didn’t.) The page also emphasized that the law now meant Medicare covered more disease-prevention services and brand-name prescription drugs than before. Transparency advocates worry that the page’s unexplained disappearance, after months of hot debate over Obamacare’s fate, could be confusing for Medicare users, leaving them wondering if their status has changed.

“Doing things quietly can oftentimes be more confusing than having a notice or having some kind of communication about why things are changing,” says Toly Rinberg, who tracks changes to .gov websites for the non-profit Sunlight Foundation. Rinberg and a team of colleagues discovered the change to Medicare.gov…

…Journalists and researchers have documented various mentions of the ACA disappearing from .gov websites. An ACA link was removed from the Department of Health and Human Services’ homepage within hours of President Donald Trump’s inauguration, The New York Times reports. Later, summaries of the law and positive user testimonies were taken down.

Rinberg says he and his colleagues, who are automatically tracking changes to about 25,000 .gov webpages having to do with health care and immigration, have seen removals of Obamacare information from numerous websites, including that of the Department of Health and Human Service, offices within the department, and other health agencies. The Sunlight Foundation plans to publish a detailed report about those changes in about a month…

May 17, 2018: Benefits Pro posted an article titled: “Obamacare startup Oscar plans expansion to new states”. It was written by Zachary Tracer. From the article:

Oscar Insurance Corp., the Obamacare-focused health insurance startup, plans to expand to Arizona and at least three other new markets next year, a bet on the health law’s survival despite the turbulent politics surrounding it.

In an interview, Chief Executive Officer Mario Schlosser said Oscar is meeting its goals to increase membership and revenue while gaining a better handle on medical costs…

…Oscar has stuck with Obamacare even after years of financial losses, as well as political uncertainty driven by the Trump administration’s push to repeal the law. After pulling back from several states for 2017, the company expanded to four markets for 2018 – Cleveland, New Jersey, Austin and Nashville – and enrolled about 240,000 members at the end of the first quarter, but from 90,000 last year…

…Schlosser said the company is expanding into four new markets, though he declined to name them because the company is still working on its filings with state regulators. Oscar will enter into close partnerships with hospitals systems, he said, as it did with the Cleveland Clinic in that hospital’s home city.

The hospital deals help Oscar make up for one of its main disadvantages to more-established health insurance rivals, which have already established networks of doctors, clinics and medical centers. By partnering, Oscar can offer customers access to care without having to rent a medical network – a costly proposition…

May 17, 2018: The New York Times posted an article titled: “Trump Administration to Tie Health Facilities’ Funding to Abortion Restrictions”. It was written by Julie Hirschfeld Davis and Maggie Haberman. From the article:

Clinics that provide abortions or refer patients to places that do would lose federal funding under a new Trump administration rule that takes direct aim at Planned Parenthood, according to three administration officials.

The rule, which is said to be announced Friday, is a top priority of social conservatives and is the latest move by President Trump to impose curbs on abortion rights, in this case by withholding money from any facility or program that promotes abortion or refers patients to a caregiver that will provide one…

…Federal family planning laws already ban direct funding of organizations that use abortion as a family planning method. But conservative activists and lawmakers have been pressing Alex M. Azar II, the secretary of health and human services, to tighten the rules further so that abortions could not occur – or be performed by the same staff – at locations that receive Title X federal family planning money.

Dawn Lagunes, the executive vice president of Planned Parenthood Federation of America, called the new proposal “outrageous” and “dangerous.”

The policy, she said in a statement Thursday, is “designed to make it impossible for millions of patients to get birth control or preventative care from reproductive health care providers like Planned Parenthood. This is designed to force doctors and nurses to lie to their patients. It would have devastating consequences across this country.”…

…Mr. Trump has shown ambivalence about Planned Parenthood, sometimes expressing support for its health-related services other than abortion. His daughter, Ivanka Trump, a senior adviser, has urged him not to strip funding for the organization, as many Republicans have proposed, warning of the possible political repercussions.

Mr. Trump is set next week to give the keynote speech at the “Champion for Life” gala held by the Susan B. Anthony List. Ms. [Marjorie] Dannenfelser [president of the Susan B. Anthony List, a group that opposes abortion rights] has called Mr. Trump “the most pro-life president of our nation’s history.”

The Trump administration has pressed repeatedly to impose abortion limits. Upon taking office, Mr. Trump signed a presidential memorandum reinstitution and expanding the so-called global gag rule, which bars federal funding for organizations around the world that provide abortion counseling or referrals.

Mr. Trump has also taken particular aim at Planned Parenthood, which serves 41 precent of women who receive federally funded family planning services. He signed legislation last year aimed at cutting off government money from the group and others that perform abortions…

…Doctors have also expressed alarm at the prospect of such changes to federal family planning rules. In a conference call this month, officials from the American College of Physicians and American College of Gynecologists said the policy would harm women’s health…

…Abortion rights advocates also argue that the new rules could result in women not receiving reproductive health care at all, leading to more unintended pregnancies and higher mortality rates. They note that Planned Parenthood and other groups that perform abortions are often the only federally funded health care providers in certain areas of the country, meaning that some women in those places may simply not receive medical care at all under the new policy…

May 18, 2018: HuffPost posted an article titled: “Trump’s New ‘Domestic Gag Rule’ Would Strip Funds from Planned Parenthood”. It was written by Laura Bassett. From the article:

The Trump administration will propose a new rule Friday that would block federal funds to any organization that provides or even shares space with an abortion provider – a domestic version of the so-called “Global Gag Rule” the president reinstated and expanded last year.

The move would notably strip Title X funding from Planned Parenthood, which provides birth control, STI testing and treatment, and cancer screenings to more than one-third of the federal family planning program’s 4 million low-income patients…

…”This is a far-reaching attack and attempt to take away women’s basic rights and reproductive rights, period,” Dawn Laguens, executive vice president of Planned Parenthood, said in a call with reporters Friday…

…Anti-abortion advocates have been pushing Trump since the beginning of his term to fulfill his campaign promise to defund Planned Parenthood, especially since Republicans in Congress have repeatedly tried and failed to do so. A coalition of conservative groups sent the administration a letter on May 1 urging them to take this step…

…Federal law already prohibits public funds from being used to pay for abortions. Women who seek abortions at Planned Parenthood or other providers must cover the cost of the procedure themselves unless their insurance plan covers it. Trump’s proposed rule would strip funds used for birth control and STD testing from organizations like Planned Parenthood and roll back a requirement that providers who receive federal subsidies for family planning services offer women information about the full range of reproductive health options, including abortion…

May 18, 2018: The White House posted a statement from the Press Secretary titled: “Statement from the Press Secretary Regarding the Proposed Title X Family Planning Program Rule from the Department of Health and Human Services.” From the statement:

The Administration’s announcement today of a proposed rule on Title X family planning program fulfills President Donald J. Trump’s promise to continue to improve women’s health and ensure that Federal funds are not used to fund the abortion industry in violation of the law.

The President is pleased to support the proposed rule from the Department of Health and Human Services (HHS), which would update the regulations governing the Title X family planning program. This important proposal would ensure compliance with the program’s existing statutory prohibition on funding programs in which abortion is a method of family planning. The new proposed rule would not cut funds from the Title X program. Instead, it would ensure that taxpayers do not indirectly fund abortions. Contrary to recent media reports, HHS’s proposal does not include the so-called “gag rule” on counseling about abortion that was part of the Regan Administration’s Title X rule.

May 18, 2018: Reuters posted an article titled: “Obamacare tied to earlier cancer detection in young women”. It was written by Shereen Lehman. From the article:

Under the Affordable Care Act (ACA) provision allowing adult children to stay on their parents’ health insurance policy until age 26, young women with gynecological cancers were diagnosed and treated sooner, researchers say.

Before the law, often called Obamacare, went into effect, one in three women ages 19 to 26 years had health insurance, and today more than four in five women in this age group are insured, the study team notes in Obstetrics & Gynecology.

In a comparison of young women who would have had access to insurance coverage under the law, and slightly older women who would not have had the same access, researchers found that 3.6 percent more of the younger group had their cancers diagnosed at an early stage…

…For their study, the researchers analyzed data from a national cancer database. They included in the analysis women aged 21 to 35 diagnosed with uterine, cervical, ovarian, vulvar or vaginal cancer during the yers 2004 to 2009, before the ACA went into effect, and 2001 to 2014, after the ACA went into effect.

Among women diagnosed at ages 21 to 26, the study team identified a total of 1,912 gynecologic cancer cases before the ACA and 2,059 during the ACA, and among women diagnosed between 27 and 35, there were 9,782 cases before ACA and 10,456 cases during the ACA.

In addition to the younger women being more likely to be insured and diagnosed when their cancer was at an earlier stage, women in both age groups were more likely to receive fertility-sparing cancer treatments during the ACA years, the study found…

…The immediate extension of insurance coverage to dependents under age 26 by the ACA in 2010 resulted in improved insurance coverage rates and earlier stage at diagnosis of uterine cancer in young women aged 21 to 25…

…Young women have traditionally faced discriminatory insurance practices such as higher insurance premiums than mean at the same age and denial of maternity coverage…

May 29, 2018: The Hill posted an article titled: “Fourth federal judge blocks Trump’s cuts to teen pregnancy prevention.” It was written by Jessie Hellman. From the article:

A fourth federal judge has ruled against the Trump administration’s decision to prematurely end grants aimed at cutting teen pregnancy rates.

Judge John Coughenour in Washington state ruled Tuesday afternoon that the administration unlawfully ended grants two years early for the King County Health Department in Seattle, which participated in the Teen Pregnancy Prevention (TPP) Program.

“This ruling is such a relief, as we are so close to the finish line for completing this study and building an evidence base for sex education nationwide,” said Patty Hayes, director of public health for Seattle and King County.

The ruling is significant as a class-action lawsuit filed by the remaining 72 grantees plays out in court.

Federal judges have now ruled in four different cases involving nine TPP grantees that the administrations actions were unlawful. The rulings mean the Department of Health and Human Services (HHS) will have to process applications for the final two years of funding…

…Trump appointees at HHS are pushing to give the TPP program a greater emphasis on abstinence education…

May 30, 2018: The White House posted a fact sheet titled: “President Donald J. Trump to Sign Right to Try Legislation Fulfilling the Promise He Made to Expand Healthcare Options for Terminal Americans”. From the fact sheet:

  • The bill amends Federal law to allow certain unapproved, experimental drugs to be administered to terminally ill patients who have exhausted all approved treatment options and are unable to participate in clinical drug trials.
  • Eligible drugs must have undergone the Food and Drug Administration’s (FDA) Phase I (safety) testing.
  • The bill requires any manufacturer or sponsor of an eligible investigational drug to report to the FDA on any use of the drug on a “Right to Try” basis.
  • The FDA wil post an annual summary report of “Right to Try” use on its website.
  • The bill limits the the liability of drug sponsors, manufacturers, prescribers, or dispensers that provide or decline to provide an eligible investigational drug to an eligible patient.
  • The FDA’s “compassionate use” application is complicated and time-consuming, resulting in only 1,200 approved applications per year.
  • With President Trump’s signature the Federal government joins with 40 states that have approved the right of terminally ill patients to try potentially life saving drugs.

May 30, 2018: Donald J. Trump @realDonaldTrump tweeted: “With the #RightToTry Law I signed today, patients with life threatening illnesses will finally have access to experimental treatments that could improve or even cure their conditions. These are experimental treatments and products that have shown great promise…”

May 30, 2018: The Hill posted an article titled: “Trump signs ‘right to try’ drug bill”. It was written by Jessie Hellmann. From the article:

President Trump signed a bill Wednesday allowing terminally ill patients access to experimental medical treatments not yet approved by the Food and Drug Administration (FDA).

Dubbed “right to try,” the law’s passage was a major priority of Trump and Vice President Pence, as well as congressional Republicans…

…Trump thanked lawmakers sitting in the audience who sponsored the bill, including Sen. Joe Donnelly, a vulnerable Democrat up for reelection in Indiana.

Despite calling Donnelly a “really incredible swamp person” earlier this month, Trump thanked the senator for his work on the bill.

Sen. Joe Manchin (W. Va.), another vulnerable Democrat up for reelection, was the only other Democratic co-sponsor on the bill, but did not attend the ceremony because he is in West Virginia this week, his office said…

…Most Democrats and public health groups oppose the bill, arguing that it could put patients in danger.

“FDA overbite of access to experimental treatments exists for a reason – it protects patients from potential sale oil salesmen or from experimental treatments that might do more harm than good,” said Rep. Frank Pallone Jr. (D- N.J.), ranking member of the House Energy and Commerce Committee.

Opponents also argue it gives “false hope” to patients, since drugmakers aren’t required to give approved medicines to patients who ask for them.

Supporters say, however, it will provide new treatment opportunities for terminally ill patients who have exhausted existing options…

May 30, 2018: NJ.com posted an article titled: “Phil Murphy signs law protecting Obamacare from Trump with N.J. mandate to have health insurance.” It was written by Susan K. Livio. From the article:

Gov. Phil Murphy on Wednesday signed a law preserving a critical yet controversial part of the Affordable Care Act that President Donald Trump’s administration repealed last year.

One of the laws creates a statewide individual mandate, which will require all New Jerseyans who don’t have health coverage through a government program like Medicare or their jobs to buy a policy, or pay a fee at tax time.

The landmark federal health care Lae, better known as Obamacare, imposed the mandate to ensure younger and healthier people who might otherwise forgo insurance will buy-in and share costs…

May 31, 2018: USA Today posted an article titled: “Virginia, after 5-year battle, passed Medicaid expansion for 400,000 poor people”. It was written by Doug Stanglin. From the article:

After a five-year battle, the Virginia legislature has voted to expand Medicaid coverage for some 400,000 poor people, despite opposition from the White House.

The Republican-controlled Senate voted Wednesday in favor of a state budget expanding Medicaid and the House of Delegates, which had previously backed the measure, gave its final approval shortly afterwards. Several Republicans in both chambers joined with Democrats to approve the measure.

Democratic Gov. Ralph Northam, a pediatrician who made Medicaid expansion a centerpiece of his campaign in 2017, is expected to sign the legislation soon…

…The votes makes Virginia the 33rd state to approve Medicaid expansion under the Affordable Care Act, or Obamacare, according to figures compiled by the Kaiser Family Foundation…

…The move also reflected the state’s sharp shift to the left in the 2017 elections in which Democrats picked up 15 seats in the House of Delegates and almost took control of the body.

In the final hours, Sen. Ben Chafin, a Republican lawmaker from Virginia’s economically depressed southwest coal country, announced his support for expansion on the Senate floor. He said his rural area needs expansion to bolster its hospitals and provide care for constituents.

“I came to the conclusion that no just wasn’t the answer anymore,” Chafin said.

Virginia GOP Speaker Kirk Cox, however, said the Trump administration’s openness to conservative reforms, including work requirements, “was probably the biggest key” in getting Republican support for the Medicaid expansion…

May 31, 2018: Bloomberg posted an article titled: “Senator Behind Right-to-Try Law Says Its Intent is to Weaken FDA”. It was written by Anna Edney. From the article:

Senator Ron Johnson, the chief sponsor of a new law giving terminally ill patients easier access to experimental drugs, said the aim of the measure is to weaken the U.S. Food and Drug Administration.

In a letter to FDA Commissioner Scott Gottleib on Thursday, the Wisconsin Republican said the goal is to “diminish the FDA’s power over people’s lives, not increase it.”

The blunt message came a day after President Trump signed the so-called right-to-try bill into law. It was in response to previous comments Gottleib had made detailing how the agency plans to implement the law.

Gottleib told the news outlet Stat this month that the FDA may need to propose new regulations to ensure that patients are protected. The agency has a program to approve patient requests for access to experimental drugs if they aren’t eligible for a clinical trial. The “right-to try” law allows patients to get the unproven medications without FDA permission…

…The law was backed by the Goldwater Institute, a libertarian think tank, and Americans for Prosperity, which is affiliated with the conservative Koch brothers….

May 31, 2018: The Democratic Governors Association (DGA) posted a letter that they sent to Secretary of Health and Human Service (HHS), Alex Azar. From the letter:

As governors representing 90 million Americans, we are deeply concerned with the Administration’s plan to undermine women’s health and place sweeping restrictions on reproductive healthcare providers across our country. For more than 40 years, Title X has been an important partnership between the federal government and states that has been supposed by Democrats and Republicans alike. This dangerous proposal would upend decades of bipartisan cooperation, taking away women’s healthcare through trusted medical providers like Planned Parenthood and eroding their access to comprehensive, medically accurate information. We strongly urge you to reconsider this plan, which is nothing more than a domestic “gag rule” that poses serious risks to women’s health.

We stand with women and men in our states by rejecting this Administration’s efforts to interfere with the doctor-patient relationship, gut women’s access to family planning services, and force medical professionals to knowingly withhold information from their patients. If the federal government breaks its commitment to states in the Title X program, we will react in kind and do what is necessary to protect the health of our constituents. We call on Americans to actively and aggressively oppose this proposed action. And if this reckless policy is finalized as written, we will have no choice but to explore all possible avenues, including legal options, to block it from harming the women in our states. Our voices will be heard on this damaging proposal, and we are prepared to match our words with actions.

We strongly urge you not to undermine the important work that Governors and administrations of both parties have done for decades to support women and families through Title X. We will continue to consult with our states’ Attorneys General, state legislatures, and state health agencies to stop this rule from harming the millions of women we are sworn to protect.

It was signed by the following Democratic Governors:

  • Governor Jay Inslee – Washington
  • Governor Gina Raimondo – Rhode Island
  • Governor Andrew Cuomo – New York
  • Governor Mark Dayton – Minnesota
  • Governor John Hickenlooper – Colorado
  • Governor Dan Malloy – Connecticut
  • Governor Steve Bullock – Montana
  • Governor David Ige – Hawaii
  • Governor Tom Wolf – Pennsylvania
  • Governor Kate Brown – Oregon
  • Governor John Carney – Delaware
  • Governor Roy Cooper – North Carolina
  • Governor Phil Murphy – New Jersey
  • Governor Ralph Northam – Virginia

June 1, 2018: Fortune posted an article titled: “Virginia Will Expand Medicaid Under Obamacare. That’s a Huge Deal for 400,000 People.” It was written by Sy Mukherjee. From the article:

A raging political battle over Obamacare came to an abrupt end Wednesday when the Virginia legislature – controlled by Republicans – voted to expand Medicaid under the health law. Newly elected Democratic Governor Ralph Northam is expected to sign the legislation, which is projected to extend health coverage to some 400,000 low-income Virginia residents…

…While Congress did nix Obamacare’s individual mandate to carry health insurance as part of the tax law signed by President Trump late last year, most of its major provisions – including the popular Medicaid expansion aimed at households earning just 138% of the Federal Poverty Level (or about $35,000 for a family of four) – remain in effect…

June 1, 2018: Des Moines Register posted an article titled: “Sen. Chuck Grassley: ‘We’ve got to give up’ on repealing, replacing Obamacare”. It was written by Luke Nozicka. From the article:

Republican Sen. Chuck Grassley this week told people gathered at an Iowa town hall that politicians should “give up” on repealing and replacing the Affordable Care Act.

During the meeting Thursday in Orange City, Grassley started answering a question about bipartisan efforts to improve the legislation before saying, “Oh, by the way, we’ve got to give up on repeal and replace.” A video of his answer was posted online by American Bridge 21st Century, a Democratic organization.

In an email, Grassley’s press secretary, Nicole Teiman, said the senator was speaking to a “mathematical reality: the votes to repeal and replace Obamacare aren’t there in the current Congress, an assessment he and other senators have expressed before.”…

…A majority of Iowans, 58 percent. said they mostly oppose the direction congressional Republicans were heading in as they crafted health care legislation, the Des Moines Register/Mediacom Iowa Poll found in July 2017. Most of those opponents, 61 percent, said the GOP’s proposed changes go to far, while 31 percent said they do not go far enough.

June 2, 2018: The Hill posted an article titled: “States defy Trump on ObamaCare”. It was written by Nathaniel Weixel. From the article:

…Several states, including California and Maryland, are looking to put limits on short-term insurance plans, even as there Trump administration is poised to expand access to them nationwide.

The states are doing so because they fear the availability of the short-term plans will drive up premium costs for ObamaCare.

On another front, Vermont and New Jersey have passed laws that require people to buy health insurance. These individual mandate laws are meant to replace the now-repealed federal requirement.

Advocacy groups and state officials that back these measures say states are seeking to protect advances made under ObamaCare from attacks by the Trump administration, which sought to repeal and replace the law and, failing that, tried to chip away at it…

…Costs are a big driver in the efforts by states.

The cost of health insurance premiums on the ObamaCare exchanges is projected to jump in the coming weeks and months. Some states could see major double-digit spikes next year.

The high costs are blamed on actions the administration has taken that could cut into ObamaCare’s enrollment.

“There’s been a series of actions taken by the current administration that have undermined enrollment,” Chet Burrell, president and CEO of CareFirst BlueCross BlueShield, said when he announced a potential 26 percent premium increase for next year in Maryland…

…Massachusetts first imposed a mandate in 2006 as part of then Gov. Mitt Romney’s (R) heart reform plan, which served as a model for ObamaCare.

Vermont’s Republican Gov. Phil Scott also signed an individual mandate bill late in May, but it won’t take effect until 2020, and many of the details, including the penalty and enforcement mechanisms, still need to be decided.

Maryland lawmakers discussed passing a mandate law for 2016, but ultimately only passed a commission to study it…

…California passed a bill that would completely prohibit the sale of short-term plans beginning in 2019, but it has yet to be signed into law.

Lawmakers in Hawaii passed a bill that would essentially eliminate the state’s short-term health plan market by prohibiting their sale to anyone eligible for a plan on the ObamaCare exchange. That bill is also awaiting the governor’s signature.

Maryland’s GOP Gov. Larry Hogan recently signed a bill that limits short-term plans to three month, and prohibits their renewal…

June 4, 2018: Reuters posted an article titled: “U.S. black lung fund will need taxpayer bailout of coal tax fails: GAO”. It was written by Valerie Volcovici. From the article:

A federal fund to help U.S. coal miners disabled by black lung disease will require a multibillion-dollar taxpayer bailout if Congress does not extend or increase the tax on coal production that funds it, according to a government report on Monday.

Coal companies are currently required to pay $1.10 per ton tax on underground coal production to finance the federal Black Lung Disability Trust Fund, which pays medical and living expenses for eligible miners, but that amount is scheduled to revert to the 1977 level of 50 cents.

“With the scheduled 2019 tax decrease, our moderate case simulation suggests that expected revenue will likely be insufficient to cover combined black lung benefit payments and administrative costs, as well as debt repayment expenditures,” according to a report from the non-partisan Government Accountability Office.

Cases of black lung, an incurable illness caused by inhaling coal dust, are rising to levels not seen in decades as miners plumb the depths of played-out coal seams using heavy blasting equipment, according to government health officials.

The fund that helps them is already roughly $6 billion in debt, as revenue since it was created in the 1970s has failed to keep up with outflows. The debt could balloon to $15 billion by 2050 without congressional action, the GAO report said.

The GAO offered three options to improve the solvency of the fund: extend the current excise tax rate to reduce the debt to $4.5 billion debt by 2050, increase the tax rate by approximately 25 percent to eliminate the debt entirely by 2050, or allow the tax rate to sunset as scheduled, cancel the current debt, and appropriate $7.8 billion to the fund.

The third option would amount to a multibillion-dollar transfer of liability for black lung victims from coal companies to taxpayers.

The coal industry has been lobbying hard against the tax, arguing its payments have already been too high at a difficult time for mining companies and that the fund has been abused by underserving applicants, such as smokers…

…The United Mineworkers Union of America, the coal miners’ trade union, called on Congress to ensure that the excise tax coal companies now pay remains at current levels, especially as the incidence of disease continues to rise and affect younger miners…

June 6, 2018: The New York Times posted an article titled: “Alex Azar, Health Secretary, Denies Sabotaging Insurance Markets”. It was written by Robert Pear. From the article:

Alex M. Azar II, the secretary of health and human services, denied on Wednesday that Trump administration policies were driving up health insurance costs, which many experts expect to surge again in 2019.

Mr. Azar, testifying before a House committee, vigorously disputed suggestions by Democrats that President Trump had sabotaged Affordable Care Act marketplaces, where millions of people obtain insurance subsidized by the federal government…

…The Congressional Budget Office said the full unsubsidized premium for a benchmark midlevel plan in the marketplaces rose 35 percent this year, on average, and was likely to increase about 15 percent next year. But some insurers have already requested rate increases of more than 30 percent for 2019…

…Insurers and consumer advocates say Mr. Trump’s efforts to undercut the Affordable Care Act have created uncertainty for insurers, causing some to withdraw from the public marketplaces…

…Nancy Pelosi, the House Democratic leader, cited news reports indicating that insurers around the country were using Trump administration policies to justify 2019 rate increases in Maine, Maryland, New York, Pennsylvania, Vermont, Virginia and Washington, among other states.

In seeking higher rates for 2019, insurers point to several developments. Mr. Trump cut off subsidies that insurers use to reduce out-of-pocket medical costs for low-income people. And Congress, with encouragement from Mr. Trump, eliminated tax penalties for people who go without insurance, starting next year, giving healthier people less incentive to obtain coverage…

…Mr. Azar did announce one policy that is likely to help consumers and insurers. He said the administration would, in effect, allow insurers to continue shifting certain costs to the federal government – because officials did not have time to issue rules banning the practice in 2019.

To offset the loss of federal “cost-sharing” payments, many insurers increased premiums this year. State officials in many states told them to load all the increases onto midlevel “silver plans,” because the federal government uses the cost of such plans as a benchmark in calculating premium subsidies. Those subsidies made insurance much more affordable, because they covered most or all of the premiums for many people this year.

Administration officials had expressed concern about the practice and considered banning it.

But Mr. Azar said, “We certainly are not able to regulate in time for the plan year” that starts in January.

He also defended the administration’s decision to allow states to impose work requirements on low-income people covered by Medicaid….

June 7, 2018: The Chicago Tribune posted an article titled: “Trump administration won’t defend Affordable Care Act in case brought by GOP states”. It was written by Amy Goldstein. From the article:

The Trump administration said Thursday night that it will not defend the Affordable Care Act against the latest legal challenge to its constitutionality – a dramatic break from the executive branch’s tradition of arguing to uphold existing statutes and a land mine for health insurance changes the ACA brought about.

In a brief filed in a Texas federal court and an accompanying letter to House Minority Leader Nancy Pelosi, D-Calif., the Justice Department agrees in large part wit the 20 Republican-led states who brought the suit. They contend that the ACA provision requiring most Americans to carry health insurance soon will no longer be constitutional and that, as a result, consumer insurance protections under the law are not valid either.

The three-page letter to Pelosi from Attorney General Jeff Sessions begins by saying that Justice adopted its position “with the approval of the President of the United States.” The letter acknowledges that the decision not to defend an existing law deviates from history but contends that it is not unprecedented.

The bold swipe at the ACA, a Republican whipping post since its 2010 passage, does not immediately affect any of its provisions. But it puts the law on far more wobbly legal footing in the case, which is being heard by a GOP-appointed judge who has in recent case ruled against more minor aspects.

The administration does not go so far as the Texas attorney general and his counterparts. In their suit, lodged in February in the U.S. District Court for the Northern District of Texas, they argue that the entire law is now invalid.

By contrast, the Justice brief and letter say that many other aspects of the law can survive because they can be considered legally distinct from the insurance mandate and such consumer protections as a ban on charging more or refusing coverage to people with preexisting medical conditions.

A group of 17 Democratic-led states that have won standing in the case also filed a brief on Thursday night arguing for the ACA’s preservation…

…It was an unusual filing just before 6 p.m. Thursday, when the brief was due, and three career Justice attorneys involved in the case – Joel McElvain, Eric Bekenhauer and Rebecca Kopplin – withdrew….

…The new challenge comes six years after the Supreme Court’s divided ruling that the ACA is constitutional. That ruling hinged on the reasoning that, while the government “does not have the power to order people to buy health insurance,” as Chief Justice John Roberts wrote for the majority, it “does have the power to impose a tax on those without health insurance.”…

…The suit is being heard by Judge Reed O’Connell, who was appointed by President George W. Bush and has ruled against the ACA in other cases the past few years…

June 7, 2018: The Hill posted an article titled: “Sessions explains to Congress rationale for not defending ObamaCare”. It was written by Julia Manchester. From the article:

Attorney General Jeff Sessions sent a letter to House Speaker Paul Ryan (R-Wis.) on Thursday defending the Department of Justice’s (DOJ) rationale for not defending the Affordable Care Act, also known as ObamaCare.

“As you know, the Executive Branch has a longstanding tradition of defending the constitutionality of duly enacted statutes if reasonable arguments can be made in their defense,” Sessions wrote.

“But not every professionally responsible argument is necessarily reasonable in this context,” he continued, adding this is “a rare case where the proper course is to forgo defense” of the law…

…Sessions’s move marks a break for the DOJ, which typically defends federal laws when they are challenged in court…

June 7, 2018: Reuters posted an article titled: “U.S. Justice Department says Obamacare individual mandate unconstitutional” From the article:

The U.S. Justice Department said on Thursday that the part of Obamacare requiring individuals to have health insurance is unconstitutional, an unusual move that could lead to stripping away some of the most significant and popular parts of the law.

In a brief filed in federal court in Texas, the department said a tax law signed last year by President Donald Trump that eliminate penalties for not having health insurance rendered the so-called individual mandate under Obamacare unconstitutional.

The Justice Department said that it also nullifies two other major provisions of Obamacare linked to the individual mandate, including one barring insurance companies from denying coverage to people with pre-existing conditions.

Attorney General Jeff Sessions, in a letter to House of Representatives Speaker Paul Ryan, said he had determined the individual mandate will be unconstitutional when the tax law becomes effective in 2019…

…Sessions said in his letter that the Justice Department was not arguing that the entire law does not pass constitutional muster. He said the department only refused to defend the pre-existing conditions provision as well as one forbidding insurers from charging people in the same community different rates based on gender, age, health status, or other factors…

June 7, 2018: The U.S. House of Representatives passed H.R. 3 “Spending Cuts to Expired and Unnecessary Programs Act”.  It is a recession bill designed allow Congress to take away appropriated funding from programs at the Departments of Agriculture, Commerce, Energy, Health and Human Services, Justice, Labor, State, Transportation, Treasury, and the Railroad Retirement Board.

H.R. 3 was sponsored by Representative Kevin McCarthy (California – Republican).

The health care related recessions included:

  • $5.1 billion from Children Health Insurance Fund – The Children’s Health Insurance Program (CHIP) provides health coverage to eligible children, through both Medicaid and separate CHIP programs. CHIP is administered by states, according to federal requirements. The program is funded jointly by states and the federal government. The President’s proposal contains two provisions related to CHIP that would simply rescind funds that are either no longer necessary or can’t be spent because the authority to do so expired last year. Rescinding these funds will likely have no impact on the program.
  • $1.8 billion from the Child Enrollment Contingency Fund – Under CHIP, the Contingency Fund provides payments to States that experience funding shortfalls due to higher than expected enrollment. At this time, the Centers for Medicare and Medicaid Services does not expect that any State would require a Contingency Fund payment in FY 2018; therefore, this funding is not needed. It is important to note that the proposal would not rescind all available funding, meaning sufficient funding would be available should a state eventually qualify for a payment.
  • $800 million from the Center for Medicare and Medicaid Innovations – Created under the Affordable Care Act, the Center for Medicare & Medicaid Innovation (the Innovation Center) with CMS supports the development and testing of innovative health care payment and service delivery models.

Some details from the text of H.R. 3 about how much will be rescinded from certain programs:

  • $5,149,512,000 from the unobligated balances of the Social Security Act are rescinded
  • $800,000,000 from the amounts made available of the Social Security Act are rescinded
  • $1,865,000,000 of the amounts deposited in the Child Enrollment Contingency Fund for fiscal year 2018 are permanently rescinded

The vote on H.R. 3 in the House of Representatives happened on June 7, 2018. The vote was 201 YEAs to 205 NAYS. This means that the bill passed the House of Representatives. Next, it would be sent to the U.S. Senate.

All of the people who voted YEA were Republicans.

19 of the people who voted NAY were Republicans:

  • Vernon Buchanan (Florida – Republican)
  • Carlos Curbelo (Florida – Republican)
  • Mario Díaz-Balart (Florida – Republican)
  • Brian Fitzpatrick (Pennsylvania – Republican)
  • Will Hurd (Texas – Republican)
  • John Katko (New York – Republican)
  • Mike Kelly (Pennsylvania – Republican)
  • Leonard Lance (New Jersey – Republican)
  • Tom MacArthur (Connecticut – Republican)
  • Brian Mast (Florida – Republican)
  • David McKinley (West Virginia – Republican)
  • Ilena Ros-Lehtinen (Florida – Republican)
  • Peter Roskam (Illinois – Republican)
  • Keith Rothfus (Pennsylvania – Republican)
  • Elise Stefanik (New York – Republican)
  • Mike Turner (Ohio – Republican)
  • Fred Upton (Michigan – Republican)
  • Jackie Walorski (Indiana – Republican)
  • Kevin Yoder (Kansas – Republican)

187 of the people who voted NAY were Democrats.

11 people did not vote:

  • Joyce Beatty (Ohio – Democrat)
  • Salud Carbajal (California – Democrat)
  • Kristi Noem (South Dakota – Republican)
  • Steven Palazzo (Missouri – Republican)
  • Jared Polis (Colorado – Democrat)
  • Terri Sewell (Alabama – Democrat)
  • John Shimkus (Illinois – Republican)
  • Bill Shuster (Pennsylvania – Republican)
  • Juan Vargas (California – Democrat)
  • Mimi Waters (California – Republican)
  • Tim Walz (Minnesota – Democratic-Farmer-Labor Party)

June 7, 2018: The Hill posted an article titled: “House passes Trump’s plan to claw back $15 billion in spending”. It was written by JulieGrace Brufke and Niv Elis. From the article:

The House voted along party lines late Thursday to pass a White House proposal that would claw back nearly $15 billion in previously approved government funding.

The House approved the measure in a vote of 210 – 206, with conservatives calling ti a step in the right direction after they ripped into the price tag of the $13 trillion spending bill President Trump signed earlier this year…

…Trump had pushed lawmakers earlier this week to vote in favor of the clawback plan, known as the Spending Cuts to Expired and Unnecessary Programs Act, which GOP leaders have been working on for two months…

…While the move was welcomed by fiscal hawks, Democrats and a handful of moderates argued it could hinder future budget negotiations and drain unused funds that may prove necessary for programs down the road.

Opponents blasted the administration’s decisions to target unobligated funds within the Children’s Health Insurance Program (CHIP) – which make up nearly half of the $14.7 billion in rollbacks – alleging the cuts could lead to a loss of coverage that is higher than expected…

…The CBO analysis supported Republican arguments that the plan would not affect children’s health. Its analysis found that the recessions would not affect any spending on children’s health, and would not affect any coverage.

But it also showed that the move would have little impact on spending.

Because the funds in question were unobligated or associated with expired programs, canceling the budget authority to spend them would do little to affect the actual spending…

…Whether the Senate will move on the measure remains unclear…

June 7, 2018: CNN posted an article titled: “Trump moves pushing up Obamacare premiums for 2019”. It was written by Tami Luhby. From the article:

…Insurers in several states have requested large rate hikes for 2019, with many pointing to steps taken by President Donald Trump and Republicans in Congress as the main reason why.

New York insurers want to hike rates by 24%, on average, while carriers in Washington are looking for a 19% average premium increase. In Maryland, CareFirst is asking for an average 18.5% rate bump for its HMO plans and a 91% spike for its PPO policies (which have far fewer enrollees), while Kaiser Permanente wants to boost premiums by more than 37% on average.

Many insurers cite two key drivers of the increases: Congress’ elimination of the penalty for the individual mandate — which requires nearly all Americans to have coverage or pay up — and the Trump administration’s expected expansion of two types of health plans that don’t have to adhere to Obamacare’s regulations…

…Jettisoning the individual mandate penalty is expected to cause premiums to rise by about 10%, the industry group said, citing reports by the Congressional Budge Office and independent actuaries. That’s because younger and healthier people will be more likely to forgo insurance since they will no longer have to pay a penalty. Insurers fear they will be left with sicker and older policyholders, prompting them to request higher rates to cover the anticipated increase in claims.

Also, Trump last year issued an executive order directing federal agencies to make it easier to buy two alternates to Affordable Care Act plans. One would allow small business to band together to buy coverage through association health plans, while the other would let Americans buy short-term coverage that would last less than a year, rather than the current 90-day limit. Both of the types of policies are expected to have lower premiums, but would cover fewer benefits — making them more attractive to healthier Americans who don’t need comprehensive coverage.

Insurers in remaining states will file proposed rates in coming weeks. Regulators will review the requests and could change them significantly. Premiums will be finalized in September and open enrollment starts November 1…

…Also, most Obamacare enrollees won’t have to pay more for coverage next year, regardless of how much insurers hike premiums. That’s because they receive federal subsidies that limit their rates to less than 10% of their income.

However, the rate hikes will hit the millions of Americans who earn too much for subsidies or who buy individual coverage outside of the Obamacare exchanges.

June 8, 2018: The American Psychiatric Association posted a news release titled: “APA Calls on Administration to Defend Patient Progections in Affordable Care Act”. From the news release:

In response to the recent decision by the Department of Justice not to defend the constitutionality of the patient protections provided in the Affordable Care Act in the federal lawsuit Texas v. United States, the American Psychiatric Association (APA) issued the following statement:

“We strongly condemn the Administration’s decision not to defend the patient protections provided in the Affordable Care Act, an established law of the land,” said APA President Altha Stewart, M.D. “In particular, this decision could lead to insurers denying coverage to the 130 million Americans with pre-exsiting conditions. This is harmful to the health of these Americans and is very short-sighted considering the nation is in the midst of an opioid epidemic and 30% rise in suicide rates. We call upon the Administration to reverse this decision and defend the rights of our patients.”

June 8, 2018: NBC News posted an article title: “Sessions takes aim at heart of Obamacare – coverage for pre-existing conditions”. It was written by Andrew Harnik. From the article:

The Trump administration said in a court filing late Thursday that it will no longer defend key parts of the Affordable Care Act, including the requirements that people have health insurance and provisions that guarantee access to health insurance regardless of any medical conditions.

The decision, announced in a court filing in Texas, is a rare departure from the Justice Department’s practice of defending federal laws in court. Texas and other Republican-led states are suing to strike down the entire law because congress recently repealed a provision that people without health insurance must pay a fine. The repeal takes effect next year.

Texas says that without the fine in place the requirement to have health insurance is unconstitutional and that the entire law should be struck down as a result.

The administration said it agrees with Texas that the so-called individual mandate will be unconstitutional without the fine. It also said that provisions shielding people with medical conditions from being denied coverage or charged higher premiums and limiting how much insurer can charge older Americans should fall as well.

But it said the rest of the law, including Medicaid expansion, can remain in place.

In many ways, the lawsuit, filed in February, is a replay of the politically divided litigation that ended with the Supreme Court upholding the health care overhaul in 2012. In the new suit, California is leading a group of Democrat-led states in defending the law.

The major difference is that the Justice Department under President Donald Trump has largely switched sides.

Attorney General Jeff Sessions said in a letter to Congress on Thursday that Trump, who campaigned on repealing the law and nearly did so in his first year in office, approved the legal strategy…

…Shortly before the government’s court filing, three career lawyers at the Justice Department withdrew from the case and were replaced by two political appointees, according to court filings.

Timothy Jost, law professor emeritus at Washington and Lee University in Virginia said the Trump administration is trying to persuade the court to do what it was unable to achieve in Congress last year – essential, repeal key parts of the Obama health law.

Jost said its telling that three career Justice Department lawyers refused to support the administration’s position….

…Despite the Justice Department position, the Health and Human Services Department has continued to apply the health law. Indeed, sign-up season for 2018 under the Trump administration resulted in only a slight enrollment drop-off from Obama’s last year.

Insurers are now finalizing their premium requests for 2019, and Jost said the Justice Department filing may prompt jittery carriers to seek higher rates…

June 8, 2018: President Trump issued a statement titled: “Presidential Message on Men’s Health Week”. From the statement:

Men’s Health Week is an opportunity to raise awareness of the diseases and illness that are most prevalent among American men and to reiterate the importance of early detection and preventative health practices. During this week, I encourage all men to evaluate both their mental and physical health hand to focus on living a healthy lifestyle.

While there are many factors that contribute to a healthy life- including diet, exercise, stress management, and mental and emotional wellness – one of the most important practices is to regularly visit the doctor and the dentist. Men are less likely than women to visit their healthcare providers, often missing out on critical treatments that can protect their overall health and wellbeing. Individuals who have routine check-ups better understand the association between a healthy lifestyle and a greater quality of life.

Although Americans are living longer, healthier lives, we cannot ignore emotional and mental health, or the stigmas that prevent individuals from seeking treatment and recovery support services as part of their overall welfare. Serious mental illness, such as major depressive disorder, has robbed too many fathers, brothers, and sones, of their potential, and has contributed to rising suicide and drug overdoses. For these reasons, my fiscal year 2019 Budget request to Congress includes $10 billion in new funding to address the opioid abuse and overdose epidemic and mental health. This funding will improve access to evidence-based treatment services to support those suffering from mental disorders and substance use disorders…

…As we observe Men’s Health Week, we celebrate the advances we have made in improving men’s healthcare, while recognizing the importance of prioritizing both physical and mental health in men of all ages.

June 8, 2018: Senator Diane Feinstein (Democrat – California) posted a press release titled: “Senate Democrats Urge Trump DOJ to Reverse Decision Not To Defend Affordable Care Act In Court”. From the press release:

…The text of the Senate Democrat’s letter can be found below:

Dear President Trump:

We are deeply concerned that you have directed the Justice Department to no longer defend the constitutionality of the Affordable Care Act, including its vitally important protections for people with pre-existing conditions. Your decision yesterday to call protections for pre-existing conditions “unconstitutional” directly contradicts the 2012 U.S. Supreme Court decision, NFIB v. Sebelius. Disturbingly, this also represents another step in your administration’s continuous attacks on the rights of people with pre-existing health conditions and we urge you to reverse this decision.

There are currently as many as 133 million non elderly Americans with a pre-existing condition – which is more than half of the people not on Medicare. Taking this position could render millions of Americans uninsurable or facing higher premiums. Prior to 2014, people with pre-existing conditions often faced higher costs or were denied coverage altogether. Under your administration, Americans have repeatedly faced the prospect of a return to the dark days in which becoming sick could mean an inability to find health insurance, women could be charged more than men, or premiums and medical costs were so high that it sent families into bankruptcy in an effort to cover the payments.

During your presidential campaign, you repeatedly promised that you would retain protections for people with pre-existing conditions. Then you changed your position and supported numerous health care bills that would have gutted these protections and repealed the entire health care act. The bills would have allowed insurers to charge more or deny coverage outright based on a person’s health status, exclude critical benefits, and once again impose annual or lifetime limits on the amount of care a person could receive. Despite the repeated failure of this legislation, your administration remains undeterred in its efforts to eliminate protections for patients for pre-existing conditions and is currently in the process of finalizing a rule to expand “junk insurance.” These plans are allowed to exclude critical types of health care coverage, deny care when a person gets sick, and charge more based on gender or a pre-existing condition. You recently indicated you plan to finalize this rule, despite knowing that not a single group representing patients, physicians, nurses or hospitals is supportive.

Mr. President, it is time to stop the sabotage. We are a country of laws, and the law must be respected, defended, and enforced regardless of the person occupying the Oval Office. It is concerning that career Justice Department officials withdrew from the case and were replaced by political appointees as the administration abandoned its defense of the law.

The American public widely supports retaining protections for pre-existing conditions. We implore you to listen to the voices of career Justice Department lawyers, as well as concerned families, patients, doctors and hospitals that want to retain these protections, and start working with Democrats to strengthen our health care system instead of trying to tear it down.

Sincerely,

  • Senator Diane Feinstein
  • Senator Charles E. Schumer
  • Senator Patty Murray
  • Senator Ron Wyden

June 8, 2018: Reuters posted an article titled: “Insurer lobby group weighs in on Obamacare individual mandate case.” It was written byTamara Mathias. From the article:

Removing certain provisions tied to the Affordable care Act, former U.S. President Barack Obama’s signature healthcare law, could strike out important consumer protections and potentially harm millions of Americans, a trade association that represents U.S. health insurers said on Friday.

The comments from America’s Health Insurance Plans (AHIP) come a day after the U.S. Justice Department called Obamacare’s individual mandate – which requires individuals to have health insurance or pay a penalty – unconstitutional…

…”Zeroing out the individual mandate penalty should not result in striking important consumer protections, such as guaranteed issue and community rating rules, that help with pre-existing conditions,” AHIP said in a statement.

Removing consumer friendly provisions like guaranteed issue, whereby health insurers cannot deny coverage to applicants or charge more based on health status, will result in renewed uncertainty in the market as well as push up rates for older and sicker patients, AHIP added…

June 8, 2018: Politico posted an article titled: “Trump’s latest health care move squeezes Republicans”. It was written by Jennifer Haberkorn and Adam Cancryn. From the article:

Republicans who have tried to repeal Obamacare for nearly a decade believe the Trump administration is reviving a politically risky battle with a court filing that could eliminate one of the most popular parts of the law: protections for people with pre-existing conditions.

The administration wants a federal court to strike the protections, providing fresh fodder to Democrats who argue that the GOP cannot be trusted to protect Americans’ health insurance months ahead of a midterm election in which health care was already a top issue. It also threatens to shift attention away from the GOP’s message on tax cuts, refocusing it on an Obamacare fight most Republicans wanted to put behind them.

The administration late Thursday asked a U.S. District Court in Texas to do something congressional Republicans weren’t willing take on themselves during last year’s repeal effort: Strike the most popular part of Obamacare.

Few congressional Republicans rushed to defend the administration’s move Friday, instead emphasizing their support for preserving pre-existing condition protections….

…Sen. Susan Collins of Maine – one of three GOP senators who blocked the Obamacare repeal effort last year – also pushed back, warning the administration’s new bid “exacerbates our current challenges” and could undermine key patient protections.

Other lawmakers points to past support for policies to prevent insurance companies from denying or dropping people with pre-existing conditions…

…Senate Democrats, who this week promised to force votes on health care during August, said the court filing proves their warnings that Republicans remain intent on repealing Obamacare through any means available…

…Within hours of the news, Democrats pounced on the Senate Republicans up for reelection this fall. The Democratic Senatorial Campaign Committee blasted releases questioning whether those Republicans – such as North Dakota hopeful Rep. Kevin Cramer – back the Trump administration’s decision…

…During last year’s repeal debate, Republicans decided to leave pre-existing conditions protections in place after they repeatedly became the subject of sometimes fiery town hall meetings with constituents…

…It is unclear how soon the U.S. District Court judge may respond to the administration’s request. If the courts strike the provision, the ruling would all but certainly be appealed – likely by a group of Democratic-led states that have weighed in on the case in courts…

…Insurance companies have already requested double-digit premium increases for 2019 in several states. The industry has blamed Trump administration decisions to undermine the health law, such as cutting off a key subsidy program to help low-income people pay their out-of-pocket health expenses…

June 8, 2018: HuffPost posted an article titled: “Democrats Say They Have Proof Health Care Can Turn Trump Voters Against Republicans”. It was written by Kevin Robillard. From the article:

…Clarity Campaigns, a Democratic polling firm, conducted the surveys in Maine’s 2nd Congressional District, a sprawling, heavily forested rural district that includes almost the entire state outside of Portland and its suburbs. The district, represented by Republican Congressman Bruce Poliquin, flipped back from backing Barack Obama by a 9-pont margin in 2012 to supporting Trump’s by 10 percentage points in 2016.

Two Democratic groups, Not One Penny and Protect Our Care, paid for the polls. They have spent the past 10 months on a sustained campaign against Poliquin in the Bangor media market, which includes half the district, and their polling shows real damage.

In a memo provided to HuffPost, Clarity Campaigns said the more voters fond out about Poliquin’s votes to repeal the Affordable Care Act and to support the GOP tax bill, the less they liked him. At the beginning of the campaign, 28 percent of voters in the media market approved of Poliquin and 38 percent disapproved. By the end, his numbers were significantly weaker: Just 25 percent approved, and 45 percent disapproved…

…The experiment reinforces the major Democratic strategy for winning back House districts where voters flipped from Obama to Trump: Focus relentlessly on unpopular GOP policies on taxes and health care, not directly on Trump’s behavior or the Russia investigation. Democrats need to win 24 seats to take back control of the House in November…

June 9, 2018: Brian Schatz (U.S. Senator from Hawaii – Democrat) posted a tweet on his verified Twitter account.  It said: “Whatever your political party of your views on the size of government or social issues or foreign policy or Rosanne or the NFL, if you are one of the 52 million Americans with a pre-existing health condition, I encourage you to vote for Democrats this year to save your healthcare.”

June 9, 2018: The American Academy of Family Physicians, American Academy of Pediatricians, American College of Obstetricians and Gynecologists, American College of Physicians, American Osteopathic Association, and American Psychiatric Association wrote a Joint Statement on Texas v United States. From the Joint Statement:

Our organizations, which represent a combined membership of more than 560,000 physician and medical student members are concerned about the Department of Justice’s decision to not defend the constitutionality of existing laws that extend patient protections to individuals in insurance markets as part of Texas v Unite States. The elimination of these protections could result in millions of people facing limited access to health care coverage and higher cost as a result of insurers being allowed to return to discriminatory coverage and pricing practices.

Our organizations disagree with the Department of Justice’s decision not to defend the protections established by the Affordable Care Act that prohibit insurance companies from denying or discontinuing coverage for individuals with pre-existing conditions or other factors such as gender or race.

As physicians who provide a majority of care to individuals for physical and mental conditions, we can speak clearly that these insurance reforms and protections are essential to ensuring that the more than 130 million Americans, especially the more than 31 million individuals between the ages of 55 an 64 who have at least one pre-existing condition are able to secure affordable health care coverage.

We strongly urge the Department of Justice to consider its decision in Texas v United States and that we all seek policy solutions that increase access to affordable health care that provides all individuals, regardless of their gender, race, and health status, reasonable protections against discrimination in coverage and pricing.

June 10, 2018: Bloomberg posted an article titled: “Health Warning: Obamacare Is in Legal Peril Once Again”. It was written by Noah Feldman. From the article:

…Just in case you haven’t thought about the individual mandate and the Constitution in the last six years, let me provide an update and a brief refresher. The update is that, in 2017, Congress passed the Tax Cuts and Jobs Act. In the law, Congress repealed the tax penalty associated with the individual mandate that everyone have health insurance.

In other words, the ACA still says you have to have insurance. But if you don’t, nothing happens to you…

…Now comes the new constitutional challenge to the ACA, filed by a group of states led by Texas. Their argument begins with the fact that, when the Supreme Court upheld the individual mandate, it did so in a very strange way. The five conservative justices all agreed that, under the commerce clause of the Constitution, Congress did not have the authority to make people buy insurance.

Their reasoning was borrowed from Prof. Barnett, who had proposed in his article that while the Congress has the power to regulate existing commercial activities, it can’t force people to undertake a commercial activity they are not already engaged in. This was the famous broccoli hypothetical: the conservatives argued that the commerce clause wouldn’t allow Congress to pass a law requiring everyone to buy and eat broccoli, even though Congress could lawfully regulate broccoli prices.

Despite this conclusion about the commerce clause, however, Chief Justice John Roberts joined the four liberals to uphold the individual mandate on the ground that it was a tax, and therefore fell within Congress’s separate taxing power. The other four conservatives were clearly frustrated with Roberts, but his vote carried the day.

The states are now arguing that once Congress repealed the tax penalty for the individual mandate in the 2017 law, no more constitutional authority exists for Congress to keep the individual mandate in place. The commerce clause is already excluded by the Supreme Court, and now the tax rationale is gone. Trump’s Department of Justice has agreed with this claim.

The states say that without the individual mandate, the whole ACA should be struck down as unconstitutional. Trump’s Justice Department didn’t go quite that far. But it did say the the ACA provisions on pre-existing conditions are so linked to the individual mandate that it should now be struck down….

…But it is entirely possible that five justices would follow the chain of formal logic laid out by the states and adopted by the Justice Department. The best argument in favor of that position is that the Obama Department of Justice told the Supreme Court years back that these provisions were interlinked – “irreversible” in legal jargon.

There is therefore a real and indeed significant chance that the most popular parts of the ACA could be struck down…

June 11, 2018: Bloomberg posted a very detailed article titled: “Air Ambulances Are Flying More Patients Than Ever, and Leaving Massive Bills Behind”. It was written by John Tozzi. From the article:

…Favorable treatment under federal law means air-ambulance companies, unlike their counterparts on the ground, have few restrictions on what they can charge for their services. Through a quirk of the 1978 Airline Deregulation Act, air-ambulance operators are considered air-carriers – similar to Delta Air Lines or American Airlines – and states have no power to put in place their own curbs.

Prices for emergency medical flights have increased dramatically, as air ambulance operators expanded their networks and responded to a wider set of emergencies, including traumas, strokes, and heart attacks.

The medical charge to Medicare for a medical helicopter flight more than doubled to almost $30,000 in 2014, from $14,000 in 2010, according to a report last year by the U.S. Government Accountability Office. Air Methods’ average charge ballooned from $13,000 in 2007 to $49,00 in 2016, the GAO said. Medicare, the federal health program for people 65 and older, pays only a fraction of billed charge; Medicaid, the state-federal program for the poor, pays even less…

…Seth Myers, president of Air Evac, said that his company loses money on patients covered by Medicaid and Medicare, as well as those with no insurance. That’s about 75 percent of the people it flies.

“I fly people based on need, when a physician calls or when an ambulance calls,” He said. “We don’t know for days whether a person has the ability to pay.”

According to a 2017 report commissioned by the Association of Air Medical Services, an industry trade group, the typical cost per flight was $10,199 in 2015, and Medicare paid only 59 percent that. Air-medical operators back U.S. legislation proposed by Senator Dean Heller of Nevada and Representative Jackie Walorski of Indiana, both Republicans, that would boost reimbursements by as much as 20 percent over three years. The bill would also have Medicare collect cost data from air-ambulance companies and use it to update rates to reflect “the actual costs of providing air ambulance services.” Both versions have co-sponsors from both parties.

For people with private insurance, short flights in an air ambulance are often followed by long battles over the bill…

…The industry says insurers put patients in the middle. “We need to hold the insurers’ feet to the fire to say we need a reasonable rate,” said Myers, the Air Evac executive. He said health plans often won’t agree to network contracts that could lower costs. He declined to say how large in-network discounts are, citing nondisclosure agreements.

Consumer groups and insurers counter that air-ambulance companies strategically stay out of health-plan networks to maximize revenue…

…Montana Senator John Tester, a Democrat, has introduced legislation that would rollback the special status of air-ambulance companies. A Federal Aviation Administration reauthorization bill passed by the House in April would make medical services provided by air ambulances subject to state regulation…

June 12, 2018: Axios posted at blog titled: “Private equity’s thirst for health care providers”. It was written by Bob Herman. From the article:

KKR’s $10 billion deal to take Envision Healthcare private, along with Bloomberg’s deep dive on the billing tactics of air ambulances, exemplifies private equity firms’ appetite for buying health care providers that weird a lot of market power.

The big picture: These companies are a leading source of surprise medical bills, which infuriate patients but are profitable for private equity owners. Emergency rooms and ambulances aren’t real marketplaces – consumers can’t stop and shop for the best price in the middle of an emergency.

The bottom line: Physician groups, emergency room staffing, and air and ground ambulances can (and in most cases do) make a lot of money because people will use their services regardless of the price…

…Physicians and ambulances can opt out of an insurance company’s network, unbeknown to a patient, if they feel they aren’t getting paid enough – and patients are saddled with the remaining costs…

…Physician and ambulance groups contend they need to bill commercial insurance more to make up for shortfalls in Medicare and Medicaid, but the cost-shifting theory often falls flat…

…The big question for the latest KKR deal: Will Envision stay transparent about its efforts to reduce surprise medical bills? Going private means health care groups don’t have to disclose a whole lot about their finances or strategy…

June 12, 2018: Politico posted an article titled: “McConnell: ‘Everybody’ in Senate likes pre-existing condition safeguards”. It was written by Jennifer Haberkorn.

Senate Majority Leader Mitch McConnell said “everybody” in the Senate wants to preserve consumer protections for people with pre-existing conditions, an Obamacare provision that the Trump administration last week said is unconstitutional and should be struck down.

“Everybody I know in the Senate – everybody – is in favor of maintaining coverage for pre-existing conditions,” McConnell told reporters in the Capitol. “There is no difference in opinion about that whatsoever.”

Obamacare’s prohibition on insurance companies canceling or denying coverage for people with pre-existing conditions is among the most popular provisions of the 2010 law. Congressional Republicans opted to preserve the idea of having a requirement last year even as they laid plans to repeal the law. Several GOP health plans last year would have barred insurance companies from denying coverage over pre-existing conditions but would have done so by requiring people to maintain continuous coverage or face higher costs or a waiting period. Critics said those requirements wouldn’t be as strong as the one in the Affordable Care Act.

The Trump administration surprised its congressional allies last week when it asked a U.S. district court in Texas to strike the provision, along with the law’s individual mandate and Obamacare’s requirement that people cannot be charged substantially more than other people in the same age range and geographic area. Democrats immediately pounced on the Justice Department move, warning they would make it a prominent issue in the midterm election…

…McConnell also touted forthcoming regulations the administration could issue as soon as this week expanding association health plans, which he said could bring down premium costs.

June 12, 2018: The Hill posted an article titled: “Warren presses health chief over Trump’s promise of drug price cuts.” It was written by Peter Sullivan. From the article:

Sen. Elizabeth Warren (D-Mass.) pressed Health and Human Services (HHS) Secretary Alex Azar on Tuesday about why no drug companies have announced price decreases despite President Trump saying they would.

Warren focused on Trump’s statement at the end of May that “in two weeks” drug companies would “announce voluntary massive drops in prices.” The two-week mark from that statement is this Wednesday.

“He said there would be massive decreases in drug prices within two weeks,” Warren said during a Senate Health Committee hearing. “It’s been two weeks and there have been no decreases and an indication of increase.” Azar counters at the hearing that there are drug companies working on price decreases…

…The health chief said the holdup is that negotiators known as pharmacy benefit managers (PBMs) are actually discouraging price decreases because that could reduce the amount of rebates that the PBMs get…

…Warren, a liberal champion who is a possible 2020 presidential contender, did not buy that argument, saying, “In the words, the president’s promise that we would see massive decreases in two weeks hasn’t happened and you don’t have anyone lined up who’s actually going to decrease drug prices.”…

June 13, 2018: The American Academy of Actuaries released an Issue Brief titled: “Drivers of 2019 Health Insurance Premium Changes”. From the Issue Brief Summary:

Key drivers of 2019 premium changes include:

  • Medical trend, which is the underlying growth in health care costs;
  • Recent legislative and regulatory changes, including the elimination of the individual mandate penalty, the pending expanded availability of short-term limited duration health plans and association health plans, and whether changes made regarding how insurers are instructed to load premiums to account for cost-sharing reduction subsidies;
  • Changes in the risk pool composition and insurer assumptions from 2018; and
  • Any state actions to implement reinsurance programs, impose individual mandate penalties, or enact rules that would facilitate or prohibit the availability of alternative coverage options.

Average premium rate changes may not represent the rate change experience by a particular consumer. A number of factors can result in a consumer’s premium differing from the average rate change, including changes in plan selection, age/family status, tobacco status, geography, or subsidy eligibility.

From the Issue Brief section titled: “Premium Changes From a Consumer Perspective”:

The following situations could result in a consumer’s premium change differing from the average premium change reflected in a premium rate filing.

  • Changes in Plan Selection: As insurers enter or exit marketplaces or otherwise change their plan offerings, consumers could have different choices of insurers or plans. If particular plans are discontinued, consumers may be re-enrolled in a different plan. Even if their current plan continues to be available, consumer may choose to enroll in a different plan. Either of these scenarios could lead to a consumer’s premium change that differs from the state’s or insurer’s average premium change.
  • Changes in Age/Family Status: Most individual consumer will experience a premium increase each year, due to aging one year.
  • The ACA allows premiums to vary by family size. Family premiums reflect the premiums for each covered adult plus the premiums for each of the three oldest covered children younger than 21. Therefore, consumers with family coverage who experience a change in family composition could face a premium change.
  • Tobacco Status: In most states, insurers are allowed to charge smokers more than nonsmokers, and this surcharge can vary by state and by age. For instance, older smokers can face higher surcharges than younger smokers. In plans that vary the surcharge by age, consumers who smoke will see a premium change due to the change in the tobacco use surcharge. In addition, consumers who have either started or stopped using tobacco products could see a premium change. Finally, carrier care allowed to change their tobacco rating factors with sufficient justification.
  • Geographic Area Factors: All states require all insurers within the state to use identical rating areas approved by the Centers for Medicare and Medicaid Services. Insurers are not allowed to change the rating areas, but they are allowed to change how premiums vary across areas due to differences in networks, relative provider charge levels, and levels of medical management.
  • While the overall impact of area factor modifications will be included in the average aggregate premium change, reported in the rate filing each insurer submits, the actual change a specific consumer experiences may vary significantly depending on where he or she lives.
  • In addition, a consumer moving from one rating area to another may experience a premium change due to the differences in area factors.
  • Subsidy Eligibility: The ACA provides premium subsidies in the individual market based on household income and the premium for the second-lowest silver plan. Changes in income alone can result in upward or downward changes in the net premiums that any specific consumer may have pay, even if there is no change in the underlying premiums. And even if there is no change in income, premium subsidies can increase if premiums increase. Changes in how states load premiums to cover cost-sharing reductions (CSRs) can also affect premium subsidies.
  • Insurers are required to notify subsidized enrollees of premium changes before open enrollment. However, the notification is based on the current year subsidy and will not reflect subsidy changes due to any premium changes, including how premiums are loaded to account for CSR’s.
  • Individuals may not be aware of the impact of the subsidy changes unless this process is changed or insurers develop additional communications. A change in available plans offered in the market also could affect the subsidy an individual receives.

June 14, 2018: The American Cancer Society posted News titled: “ACS CAN filed legal brief in support of protections for people with serious health needs”. From the News:

The American Cancer Society Cancer Action Network (ACS CAN) joined with four other national patient advocacy organizations today to file a legal brief or amicus curiae that describes the devastating impact patients would face if the district court rules the Affordable Care Act is not a valid law.

Twenty states, led by Attorney General of Texas, recently filed a lawsuit, Texas v United States of America. They argue that the Affordable Care Act must be struck down because it cannot stand now that Congress repealed the tax penalty that a person receives if they do not have health care coverage.

ACS CAN and the other patient groups urged the court in their legal brief to uphold the Affordable Care Act and to “recognize Congress’s clear intent to improve access to lifesaving health care for millions of Americans.”

The Department of Justice (DOJ) is typically responsible for defending the country’s laws, but, in this case, the Department has filed a brief declining to defend the Affordable Care Act.

The DOJ argues that certain protections the health care law guarantees for people with pre-existing conditions are invalid.

If the Affordable Care Act is struck down, this could have dire consequences, leaving millions of Americans with serious illnesses like cancer unable to get health care coverage. Studies show that uninsured patients are less likely to be screened for cancer, and are more likely to be diagnosed at more advanced stages of their cancer when it is harder and more expensive to treat.

“If people don’t have real health insurance – comprehensive health insurance – they die,” said Mary Rouvelas, senior counsel at ACS CAN.

Since the Affordable Care Act was signed into law, more people have signed up for health care coverage and the uninsured rate has decreased by more than six percent nationwide.

In a joint statement, ACS CAN and the patient groups said in reference to the health care law, “This has improved patients’ ability to prevent, detect, and treat their disease. For instance, there is already a small but statistically significant shift toward early-stage diagnosis for colorectal, lung, breast and pancreatic cancer in states that have increased access to health care through Medicaid because of the law.”

June 14, 2018: HuffPost posted an article titled: “They Fought Over the Last Obamacare Lawsuit, But They Agree This One Is Nonsense”. It was written by Johnathan Cohn. From the article:

Five scholars who argued with each other over past legal challenges to the Affordable Care Act have joined forces to file a friend of the court brief about a new lawsuit that could wreck the law.

They all think the courts should reject the lawsuit. And they don’t think it’s a particularly close call.

The lawsuit, Texas v. United States, comes from Republican officials in 20 states and alleges that the 2010 health care law is unconstitutional. Last week, the Justice Department declined to defend the law, breaking from the customary role the federal government plays when states challenge a federal statute…

…The case is now before a federal district judge in Texas. On Thursday, five well-known scholars were among those filing briefs urging the judge to reject the lawsuit.

The five are Johnathan Adler from Case Western Reserve University, Nicholas Bailey from the University of Michigan, Abbe Gluck from Yale University, Ilya Somin from George Mason University, and Kevin Walsh from the University of Richmond…

…Adler was actually an architect of the lawsuit in King v Burwell, which could have crippled the Affordable Care Act’s newly created private insurance markets in a majority of states. He filed a brief in the case and, and in a series of articles and public appearances, frequently squared off with Bailey and Gluck, who collaborated on their own brief in defense of the law.

The Supreme Court rejected that lawsuit in 2015. It was the second time the high court upheld the constitutionality of the law known as Obamacare. The first time was in 2012, in a case called NFIB v. Sebelius. Somin was an influential, high-profile supporter of the lawsuit and the author of a brief supporting it.

As for Walsh, he is an expert on “severability,” which is the legal doctrine about when a court must strike down an entire law, or large parts of it, because it has found one piece to be unconstitutional. Justice Clarance Thomas just cited one of Walsh’s briefs in a recent Supreme Court decision on the subject…

The Amici Curiae was posted by The Incidental Economist and is available to view as a PDF.

June 14, 2018: CBS News posted an article titled: “Pre-existing conditions coverage at risk for more than thought?” From the article:

…Two independent experts said Wednesday that the administration appears to be taking aim at provisions of the ACA that protect people in employer plans, not only the smaller pool of consumers who buy a policy directly from an insurer. The new Trump administration position was outlined last week in a legal brief filed by the Justice Department in a Texas case challenging the Obama health law.

Workers “could face the prospect of insurance that doesn’t cover their pre-existing conditions when they enroll in a plan with a new employer,” said Larry Levitt of the nonpartisan Kaiser Family Foundation.

University of Michigan law professor Nicholas Bailey said the administration does not appear to have thought through all the consequences of moving against one provision of a health law that has many complicated interlocking parts.

“The lack of care on the brief is jaw-dropping,” said Bagley, who supports the Obama health law but considers himself a “free agent” critic of both sides. “There is no question that the Trump administration has to clarify what the scope of its injunction would be and grapple with the consequences of mowing down parts of the ACA.

“For someone with a pre-existing condition thinking about switching jobs, the answer to that question could make a life-changing difference,” added Bagley…

…Nearly 160 million workers and family members have coverage through employers, although the number covered by small employers is much smaller.

June 15, 2018: Two Cents posted an article titled: “You Could Be Denied Pre-Existing Conditions Coverage by Employer Health Plans if the ACA Is Repealed”. It was written by Alicia Adamcyzk. From the article:

…If you don’t care much about the issue because you have insurance through your employer, it could affect you too. That’s because the provisions that the Trump administration is contesting apply to all private health coverage, including employer plans.

Before the ACA, your employer plan couldn’t deny you coverage or charge you more, but it could exclude coverage for your pre-existing conditions for a year if you don’t maintain continuous coverage. That’s what the plans would revert to if the ACA’s provisions are overturned. (Large and small group plans would face worse outcomes.)

As Timothy Jost, an Demetrius professor of law at Washington and Lee University writes, the biggest impact on those with employer insurance is that it would “lock you into” your jobs once again. The ACA gave some people more freedom to leave jobs and pursue entrepreneurial or freelance jobs, because they were guaranteed to find health insurance coverage… It also gives more freedom to leave an unfailing job you’re keeping simply for the benefits. That wasn’t a given before, and it could be on the line again…

June 19, 2018: AHIP posted a statement titled: “AHIP Comments on Final Rule Expanding the Use of Association Health Plans”. From the statement:

America’s Health Insurance Plans (AHIP) issued the following statement after the Department of Labor issued its final rule expanding the use of the Association Health Plans (AHP).

“Every American should be able to get comprehensive health care coverage they can afford, and we support the goal of increasing competition and choice in ways that improve affordability. The final rule provides some important protections by ensuring consumers, including those with pre-existing conditions, do not face discrimination as new association plans are created, and by preserving state authority to regulate AHPs offered in their markets.

“However, we remain concerned that broadly expanding the use of AHP’s may lead to higher premiums for consumers who depend on the individual or small group market for their coverage. Ultimately, the rule could result in fewer insured Americans and may put consumers at greater risk of fraudulent actors entering this market.

“We will continue to work with the Administration, Congress, and state leaders to ensure that all coverage markets remain steady and reliable for all Americans.”

June 19, 2018: The Washington Post posted an article titled: “House GOP plan would cut Medicare, Medicaid to balance budget”. It was written by Erica Werner. From the article:

…The House Republican budget, titled “A Brighter American Future,” would remake Medicare by giving seniors the option of enrolling in private plans that compete with traditional Medicare, a system of competition designed to keep costs down but dismissed by critics as an effort to privatize the program. Along with other changes, the budget proposes to squeeze $537 billion out of Medicare over the next decade.

The budget would transform Medicaid, the federal-state health-care program for the poor, by limiting per capita payments or allowing states to turn it into a block-grant program – the same approach House Republicans took in their legislation that passed last year to repeal the Affordable Care Act (the repeal effort died in the Senate, but the GOP budget assumes the repeal takes place). It also proposes adding work requirements for certain adults enrolled in Medicaid. Changes to Medicaid and other health programs would account for $1.5 trillions in savings.

Social Security comes in for more modest cuts of $4 billion over the decade, which the budget projects could be reached by eliminating concurrent receipt of unemployment benefits and Social Security disability insurance.

The budget also proposes a number of other cost-saving measures, some of which could prove unpopular if implements, such as adding more work requirements for food-stamp and welfare recipients and requiring federal employees  – including members of Congress – to contribute more to their retirement plans….

A legal brief filed by ACS CAN, American Heart Association, American Lung Association, American Diabetes Association, and the National Multiple Sclerosis Society is available to read online.

June 19, 2018: The Center on Budget and Policy and Priorities posted a CBPP statement titled “Greenstein: House Budget Committee 2019 Budget Continues Trend of Harsh, Deep Cuts” It was written by Robert Greenstein. From the statement:

House Budget Committee Chairman Steve Womack’s new 2019 budget shows that the House majority’s fiscal priorities haven’t changed. The budget plan maintains the costly 2017 tax cuts, while making deep cuts in health care and basic assistance for struggling families, repealing the Affordable Care Act (ACA), and severely cutting funding over time for investments that can boost the nation’s productivity and thereby foster economic growth.

The committee’s materials show that the budget would make nearly $6 trillion in cuts over ten years to entitlements and non-defense discretionary programs, including $2.1 trillion in health care alone, including to Medicaid, ACA premium tax credits, and Medicare. The budget incorporates the failed House ACA repeal bill, which, at the time the bill was considered, the Congressional Budget Office estimated would have taken away health coverage from 23 million Americans by 2026. (This estimate includes the effect of repealing the individual mandate, which Congress has since enacted.)…

June 20, 2018: The United States Senate voted on H.R. 3 “Spending Cuts to Expired and Unnecessary Programs Act”.  The vote was 48 YEAS to 50 NAYS.  This bill required at least 51 YEA votes to pass. It only got 48 YEA votes.

Senators who voted YEA:

  • Alexander (R-TN)
  • Barrasso (R-WY)
  • Blunt (R-MO)
  • Boozman (R-AR)
  • Capito (R-WV)
  • Cassidy (R-LA)
  • Corker (R-TN)
  • Cornyn (R-TX)
  • Crapo (R-ID)
  • Cruz (R-TX)
  • Daines (R-MT)
  • Enzi (R-WY)
  • Ernst (R-IA)
  • Fischer (R-NE)
  • Flake (R-AZ)
  • Gardner (R-CO)
  • Graham (R-SC)
  • Grassley (R-IA)
  • Hatch (R-UT)
  • Heller (R-NV)
  • Hoeven (R-ND)
  • Hyde-Smith (R-MS)
  • Inhofe (R-CA)
  • Isakson (R-GA)
  • Johnson (R-WI)
  • Kennedy (R-LA)
  • Lankford (R-OK)
  • Lee (R-UT)
  • McConnell (R-KY)
  • Moran (R-KS)
  • Murkowski (R-AK)
  • Paul (R-KY)
  • Perdue (R-GA)
  • Portman (R-OH)
  • Rich (R-ID)
  • Roberts (R-KS)
  • Rounds (R-SD)
  • Rubio (R-FL)
  • Sasse (R-NE)
  • Scott (R-SC)
  • Shelby (R-AL)
  • Sullivan (R-AK)
  • Thune (R-SD)
  • Tooney (R-PA)
  • Wicker (R-MS)
  • Young (R-IN)

Senators who voted NAY:

  • Baldwin (D-WI)
  • Bennet (D-CO)
  • Blumenthal (D-CT)
  • Booker (D-NJ)
  • Brown (D-OH)
  • Burr (R-NC)
  • Cantwell (D-WA)
  • Cardin (D-MD)
  • Carper (D-DE)
  • Casey (D-PA)
  • Collins (R-ME)
  • Coons (D-DE)
  • Cortez Masto (D-DE)
  • Donnelly (D-IN)
  • Duckworth (D-IL)
  • Durbin (D-IL)
  • Feinstein (D-CA)
  • Gillibrand (D-NY)
  • Harris (D-CA)
  • Hassan (D-NH)
  • Heinrich (D-NM)
  • Heitkamp (D-ND)
  • Hirono (D-HI)
  • Jones (D-AL)
  • Kaine (D-VA)
  • King (I-ME)
  • Klobuchar (D-MN)
  • Leahy (D-VT)
  • Manchin (D-WV)
  • Markey (D-MA)
  • McCaskill (D-MO)
  • Menendez (D-NJ)
  • Merkley (D-OR)
  • Murphy (D-CT)
  • Murray (D-WA)
  • Nelson (D-FL)
  • Peters (D-MI)
  • Reed (D-RI)
  • Sanders (D-VT)
  • Schatz (D-HI)
  • Schumer(D-NY)
  • Smith (D-MN)
  • Stabenow (D-MI)
  • Tester (D-MT)
  • Udall (D-NM)
  • Van Hollen (D-MD)
  • Warner (D-VA)
  • Warren (D-MA)
  • Whitehouse (D-RI)
  • Wyden (D-OR)

Senators who did not vote:

  • McCain (R-AZ)
  • Shaheen (D-NH)

June 20, 2018: The Press Herald posted an article titled: “Senate rejects billions in Trump spending cuts as 2 Republicans, including Collins, vote ‘no'”. It was written by Erica Werner. From the article:

The Senate on Wednesday rejected billions in spending cuts proposed by the Trump administration as two Republicans joined all Democrats in voting “no”.

The 48-50 vote rebuffed a White House plan to claw back some $15 billion in spending previously approved by Congress – a show of fiscal responsibility that was encouraged by conservative lawmakers outraged over a $1.3 trillion spending bill in March.

The House had approved the so-called “recessions” package earlier this month. But passage had never been assured in the Senate, where a number of Republicans had been cool to the idea from the start.

Nevertheless, Wednesday’s outcome was startling because one of the “no” votes came from Sen. Richard Burr (R-NC), who does not normally buck the White House or leadership. Burr’s office had no immediate comment.

Sen. Susan Collins (R-Maine), a moderate who is one of the Republicans who most frequently sides with the Democrats, cast the other ‘no’.

The cuts in the recessions package included $7 billion from the Children’s Health Insurance Program, mostly from an expired account that can no longer be used; $5 billion from Energy Department programs, including a little-used loan program for advanced technology vehicle manufacturing; and smaller amounts from a variety of other programs ranging from Forest Service land acquisition to the Millennium Challenge Corp…

June 20, 2018: Politicus USA posted an article titled: “As America Is Distracted By Trump Child Abuse, GOP Moves To Gut Medicare And Medicaid”. It was written by Jason Easley. From the article:

While the American people are rightly outraged by the Trump administration’s abuse abuse of migrant children, House Republicans proposed a budget that would gut Medicare and Medicaid.

The 2019 budget that Republicans are working on in the House Budget Committee would pay for tax cuts with a gutting of Medicare and Medicaid.

According to The Center for Budget and Policy Priorities, “House Budget Committee Chairman Steve Womack’s new 2019 budget shows that the House majority’s fiscal priorities haven’t changed. The budget plan maintains the costly 2017 tax cuts, while making deep health care and basic assistance for struggling families, repealing the Affordable Care Act (ACA), and severely cutting funding over time for investments that can boost the nation’s productivity and thereby foster economic growth. The committee’s materials show that the budget would make nearly $6 trillion in cuts over ten years to entitlement and non-defense discretionary programs, including $2.1 trillion in health care alone, including cuts to Medicaid, ACA premium tax credits, and Medicare. The budget incorporates the failed House ACA repeal bill which, at the time the bill was considered, the Congressional Budget Office estimated would have taken away health coverage from 23 million Americans by 2026.”…

June 20, 2018: Forbes posted an article titled: “Once More Into The Breach: Conservative Think Tankers Publish A New Obamacare Replacement”. It was written by Avik Roy.

Conservative health care think tank scholars have published a new proposal to repeal and replace Obamacare, hoping that they can persuade Congress to take up the issue one more time before November. Can it succeed where prior efforts have failed?

The proposal, entitled “The Health Care Choices Proposal: Policy Recommendations to Congress – Why Congress Much Act,” was published by the Health Policy Consensus Group, a kind of conservative health wonk Jedi Council led by Grace-Marie Turner of the Galen Institute, who is also a Forbes contributor. (I am also a participant in the Consensus Group.)

The plan emerged from the aftermath of the 2017 effort by Bill Cassidy (R., La.) and Lindsey Graham (R., S.C.) to put forth an Obamacare replacement after all the previous efforts by congressional GOP leadership had failed. The Graham-Cassidy bill…was designed to preserve the vast majority of Obamacare’s spending on the uninsured, but reformat that spending as block grants to state governments.

The critical flaw in Graham-Cassidy is that it bore the potential to make health insurance markets work, not better, because due to design flaws in the bill, most states would have been strongly incentivized to eliminate their private individual insurance markets and replace them with an enlarged expansion of Medicaid, a program whose enrollees have health outcomes no better than those who are uninsured.

…The Consensus Group proposal improves upon Graham-Cassidy by requiring that “at least 50% of the block grant goes toward supporting people’s purchase of private health coverage” in the individual insurance market. Under the new program, states would be required to offer Market enrollees the opportunity to purchase “commercially available coverage” with their Medicaid dollars, and plans sold under the block grants would be exempted from costly Obamacare rules, like 3:1 age bands that double the triple the costs of insurance for young people.

The proposal would also double contribution limits to health savings accounts, and it would reform the limits on what kinds of insurance can be associated with HSAs:

The Proposal would make more HSA-compatible. Today, in order to be HSA-compatible, a policy must have a deductible of a least $1,350 ($2,700 for families). The average Obamacare Silver plan had deductible of at $4,033 ($8,292 for families). In 2016, more than four of every five plans on the federal exchange had deductibles greater than the legal minimum for HSAs, but less than a fifth were HSA-eligible. This proposal would change the requirement to qualify, so that any plan with an actuarial value less than a specified (e.g., 70%, 80%) could be HSA-compatible…

…The likelihood that the Consensus Group proposal becomes law is low. And that’s despite the fact that its focus is narrow; it doesn’t attempt to reform the pre-Obamacare Medicaid program or any of our other health are entitlements, nor does it try to tackle the underlying reasons why health care is so expensive in the first place.

Graham-Cassidy died because there weren’t enough votes in the Senate to support it. Republicans control 51 seats in the Senate right now, and one of those belongs to John McCain (Ariz.), who is battling brain cancer and is rarely in Washington. Hence, every other GOP senator has to vote “aye” for any health care bill to pass.

And they can’t get to 50. Kentucky Sen. Rand Paul (R.) has repeatedly expressed his opposition to any plan that replaces Obamacare with subsidies for the uninsured. Mike Lee (R. Utah) has also been generally unfriendly to robust replacement bills. And that’s before you even get to the moderate Republican senators, who have their own suite of concerns. Democrats are almost certainly unwilling to entertain a proposal in which the word “uninsured” appears exactly zero times…

June 21, 2018: John Yarmuth (Ranking Member of the House Budget Committee), (Kentucky – Democrat) posted a statement on the House Committee on the Budget Democrats website. From the statement:

Kentucky Congressman John Yarmuth, Ranking Member of the House Budget Committee, issued the following statement after the Republican majority voted to pass the House Republican 2019 budget and rejected every amendment offered by Democrats:

“Today, during consideration of the Republican budget, Democrats offered amendment after amendment to advance the needs and priorities of the American people. We proposed protecting Medicare, Medicaid and Social Security, ending extreme cuts to infrastructure, education and nutrition assistance, and even ensuring that surviving military spouses receive full benefits with no penalties. At every turn, Republicans voted to protect their $2 trillion in tax cuts for millionaires and big corporations instead of American families.”

June 21, 2018: Topher Spiro (Senior Fellow, Economic Policy and VP, Health Policy at American Progress) posted a thread on his verified Twitter account that started with this tweet: “BREAKING: The House GOP just voted a budget bill out of committee that fast tracks ACA repeal and $2 TRILLION in cuts to Medicare and Medicaid. We need to flood them with calls to prevent a floor vote.”

June 21, 2018: USA Today posted an article titled: “Obamacare: Outreach groups nervous as Trump remains silent on funding.” It was written by Ken Alltucker. From the article:

A year after steep cuts to a key Affordable Care Act outreach program, the Trump administration has remained quiet on how much it will fund nonprofit and grass-roots groups that help people sign up for health insurance.

The federal navigator program funds groups that help people to sign up for health insurance on the Obamacare federal and state insurance exchanges or assist low-income adults and children sign up for Medicaid coverage.

Navigator groups located in federal exchange states are funded through September but have no idea how much money will be available then. The six-week open enrollment period that allow consumers to choose a plan for the upcoming year begins Nov. 1…

…The Trump administration, which has been critical of the efficiency of these groups, has reshaped the Obama-era program to operate with limited resources, according to an HHS draft rule.

Under new HHS regulations that took effect June 18, navigator groups would no longer need to be physically located in the states they serve. The new regulations also eliminate a requirement that at least one navigator group in a community be a consumer-focused nonprofit…

…Administration officials would not say when the funding details will be publicly released leaving navigator groups in limbo on budgets to prepare for this year’s six-week enrollment starting Nov. 1.

Last year, the Trump administration cut funding to the navigator program more than 40 percent weeks before the start of signups. While the administration has not publicly revealed budgets for the year. HHS officials noted that limited resources are a driving factor for the proposed regulatory overhaul this year…

June 22, 2018: Nancy Pelosi (Minority Leader of the U.S. House of Representatives) (California – Democrat) posted a tweet on her verified Twitter account: “It’s been 6 months since Republicans forced the $1.5 trillion #GOPTaxScam for the rich. It’s been ~24 hours since they voted to steal over $2 trillion from Medicaid, Medicare, Social Security and other key investments. They really don’t care about the harm they’re inflicting.”

June 22, 2018: Sun-Sentinel posted an article titled: “South Florida’s 3 Obamacare providers file proposals to return in 2019”. It was written by Ron Hurtibise.  From the article:

…Three companies that offered 2018 plans in South Florida are back – market leader Florida Blue, which has been offering a wide array of plans to fit all budgets and circumstances – plus narrow-network, lower-cost alternatives Molina Healthcare and Ambetter.

All three submitted 2019 rate proposals with the Florida Office of Insurance Regulation as required by June 20, along with four other companies that filed to sell plans in other areas of the state.

In all, rate increases proposed by eight companies offering ACA-compliant plans on and off the exchange, average 8.8 percent, according to a news release by the state office late Friday afternoon.

That compares with a 17.8 percent increase requested a year ago by the same companies….

…Of the 1.7 million Floridians who enrolled in 2018 marketplace plans, 92 percent qualified for subsidies and saw an average $595 monthly premium reduced to $70, according to data maintained by the Department of Health and Human Services. In the tricounty region, 762,000 are enrolled…

…A new company has even filed to offer ACA plans in the state. Oscar Health, which currently sells plans in California, Texas, and New York, on Thursday announced plans to expand into Florida, Michigan and Arizona in 2019…

…Market giant Florida Blue, which absorbed most of the policies abandoned by competitors Aetna, Cigna, UnitedHealthcare and Humana after Obamacare’s first three years, plans to remain in all 67 Florida counties…

June 24, 2018: Forbes posted an article titled “Poll: 66% Of Voters Oppose Trump DOJ’s Move To Gut Patient Protections”. It was written by Bruce Japsen. From the article:

By a 2-to-1 margin, U.S. voters disapprove of the U.S. Justice Department’s decision to support a lawsuit that would eliminate popular protections for patients with preexisting conditions under the Affordable Care Act, a new poll shows…

…The survey of more than 1,000 likely voters by Hart for the group Protect Our Care was conducted June 11 to 17 following the action by Republican state attorneys general to challenge the constitutionality of consumer insurance programs like the ban on refusing coverage or charging higher premiums to Americans with pre-exiting conditions.

The poll, which is the latest to show growing support for the ACA, and its consumer protections in particular, shows 66% of voters disapprove of the Trump Justice Department’s move and nearly half, or 47% of all voters “strongly disapprove” of the lawsuit gutting the ACA’s consumer protections. Only 11% strongly approve, the survey shows…

…Already, providers of medical care and health insurers have voiced strong opposition to the Justice Department’s brief in support of Texas and 19 other states attempt to declare as unconstitutional protections for patients with pre-existing conditions.

June 26, 2018: The Kansas City Star posted an article titled: “Insurer plans to expand Obamacare offerings into Missouri counties in KC area”. It was written by Andy Marso. From the article:

Another insurance company has filed to sell plans on the Affordable Care Act exchange in Kansas City next year, possibly bringing the total to three just one year after it appeared the city might have only one option.

Minnesota-based Medica announced this week it has filed documents with the Missouri Department of Insurance to sell its Select plan in Cass, Clay, Jackson and Platte counties.

The plan, which limits hospital coverage to St. Luke’s Health System locations, is now offered only to residents of Johnson and Wyandotte counties in Kansas…

…Medica’s announcement is the latest in a slew of market changes for the area’s Affordable Care Act, commonly called Obamacare, marketplace.

Major insurers like UnitedHealthcare and Blue Cross and Blue Shield of Kansas City have gotten out, but new players like Medica and Centene, with its “Ambetter” plans, have jumped in.

The one constant in the Missouri counties of the metro over the last few years has been Cigna. If the Connecticut-based insurer and Centene stay for 2019, then people in Jackson, Clay, Cass and Platte counties will have three companies to choose from when open enrollment starts in November.

Johnson County and Wyandotte County have also seen turnover the last few years. But according to the Kansas Insurance Department, Medica, Centene and Blue Cross Blue Shield of Kansas have again filed their intent to sell 2019 plans that are similar to what they’re offering those year. That would be Medica throughout the state, Centene in Johnson County and Wyandotte County, and BCBS Kansas in every county except Johnson and Wyandotte…

June 27, 2018: SunSentinel posted an article titled: “South Florida’s 3 Obamacare providers file proposals to return in 2019”. It was written by Ron Hurtibise. From the articles:

…The three companies that offered 2018 plans in South Florida are back – market leader Florida Blue, which has been offering a wide array of plans to fit all budgets and circumstances – plus narrow-network, lower-cost alternatives Molina Healthcare and Ambetter.

All three submitted 2019 rate proposals with the Florida Office of Insurance Regulation as required by June 20, along with four other companies that filed to sell plans in other areas of the state.

In all, rate increases proposed by eight companies offering ACA-compliant plans on and off of the exchange, average 8.8 percent, according to a news release by the state office late Friday afternoon.

That compares with a 17.8 percent increase requested a year ago by the same companies…

…Of the 1.7 million Floridians who enrolled in 2018 marketplace plans, 92 percent qualified for subsidies and saw an average $595 monthly premium reduced to $70, according to data maintained by the Department of Health and Human Services. In the tricounty region, 762,000 are enrolled…

…A new company has even filed to offer ACA plans in the state. Oscar Health, which currently sells plans in California, Texas and New York, on Thursday announced plans to expand into Florida, Michigan and Arizona in 2019…

June 27, 2018: Kaiser Family Foundation posted an article titled: “Poll: Two-thirds of Voters Say a Candidate’s Position on Pre-existing Conditions is Important to their Vote, More than Say the Same about Drug Costs, ACA Repeal or Medicare-for-all”.  From the article:

About two-thirds (65%) of voters say a candidate’s support for continued protections for people with pre-existing health conditions is either the “single most important factor” or “very important” to their vote in the upcoming midterms elections, finds the Kaiser Family Foundation tracking poll.

That’s a larger share than says the same about other health care issues, including bringing down prescription drug costs (58%), repealing the Affordable Care Act (53%), stabilizing the ACA marketplaces (52%), or passing a national health plan or Medicare-for-all (48%), the poll finds.

There are differences by partisan identification. Eight in 10 Democratic (81%) and nearly two-thirds (63%) of independent voters say the issue is at least “very important” to their vote – making it top health care issue for both groups of voters. About half (51%) of Republican voters say the same, ranking the issue below repealing the ACA (58%) among Republicans….

…Almost six in 10 Americans (57%) say that they or someone in their household has a pre-existing condition of some sort, the poll finds. This includes majorities of men and women, and majorities in all age groups except those under 30.

Among the general public, large majorities say that the ACA’s provisions that bar insurers from discriminating against people with pre-existing conditions are “very important” to them, the poll finds…

June 29, 2018: NPR posted an article titled “Federal Judge Blocks Medicaid Work Requirements In Kentucky”. It was written by Alison Kodjak. From the article:

A federal judge has blocked work requirements for Medicaid patients in Kentucky, just days before new rules mandated by Gov. Matt Bevin’s administration were set to go into effect.

In Friday’s ruling, U.S. District Judge James Boasberg called the Trump administration’s approval of the program, Kentucky HEALTH, “arbitrary and capricious”.

He writes that in approving Kentucky’s work requirement proposal, Health and Human Services Secretary Alex Azar “never adequately considered whether Kentucky HEALTH would in fact help the state furnish medical assistance to its citizens, a central objective of Medicaid.”

The judge pointed out that Azar did not mention that 95,000 people could lose coverage under the plan – an oversight that he called “glaring”…

…Bevin filed a counter lawsuit in February and has threatened to dismantle Kentucky’s Medicaid expansion if the courts do not allow him to add the work requirement.

HHS approved Bevin’s request to change Kentucky’s Medicaid program in January. It requires “able bodied” Medicaid recipients  to either find work, do job training or do volunteer work to be eligible for Medicaid benefits. It was the first state to get such approval, after Seema Varma, the administrator for the Centers for Medicare and Medicaid Services, said she would look favorably on such proposals.

Verma said in a statement that she is disappointed by the decision..

…She said the agency is talking with the Justice Department to decide whether to appeal…

…Verma and Azar have argued that Medicaid beneficiaries will benefit from what’s known as “community engagement” requirements because finding work will help lift them from poverty, and therefore improve their health.

But the judge didn’t buy that argument…

…HHS has approved work requirements for Medicaid in four states. An additional seven states have requests awaiting agency approval, according to the Kaiser Family Foundation.

The ruling is available to view online. The case is called “Ronnie Maurice Stewart, et. al., v. Alex M. Azar II, et. al.,”  From the ruling:

In 2010, Congress enacted the Patient Protection and Affordable Care Act – popularly known as Obamacare – which is “a comprehensive national plan to provide universal health insurance coverage” across the nation… …One central component of that statute was an expansion of Medicaid, allowing states to provide “health care to all citizens whose income falls below a certain threshold.”… …The “expansion,” the Supreme Court has held, represented “a shift in kind, not merely degree.”… …While the “original program was designed to cover medical services for four particular categories of the needy: the disabled, the blind, the elderly and needy families with dependent children,” the Affordable Care Act “transformed” Medicaid “into a program to meet the health care needs of the entire non elderly population with income below 133 percent of the poverty level…

…Defendants in this case sought to roll back those reforms. Upon assuming office in March 2017, Defendant Seema Verma, the Administrator for the Centers of Medicare & Medicaid Services – along with then-Secretary of the Department of Health and Human Services Tom Price – immediately circulated a letter to the Governors of all states to share her belief that the ACA’s Medicaid expansion”was a clear departure from the core, historical, mission of the program.”…

…The letter encouraged states to apply for “waiver[s]” of some of the program’s coverage requirements – especially for the expansion group – promising to “fast-track” approval of such petitions…

…Kentucky is one state to board that train. After the ACA went into effect, it elected to broaden Medicaid to include the expansion population, and by April 2016, more than 428,000 new residents had thereby received medical assistance. In July 2017, however, the state submitted an experimental plan to CMS called “KY HEALTH,” which is made up of several components, most significantly Kentucky HEALTH. That latter program promised to “comprehensively transform” its Medicaid program.

Under that plan, the state would impose “community engagement” requirements for the expansion population, along with some of the traditional population as well. This new mandate would require that those recipients work (or participate in other qualifying activities) for at least 80 hours each month as a condition of receiving health coverage. The project also called for, among other things, increased premiums and more stringent reporting requirements. Consistent with CMS’s earlier invitation, the Secretary approved Kentucky’s application on January 12, 2018, waiving several core Medicaid requirements in the process.

Plaintiffs in this case are fifteen Kentucky residents, each of whom is currently enrolled in the state’s Medicaid program. Together, they fear that that Kentucky HEALTH will relegate them to second-class status within Medicaid, putting them and others “in danger of losing” their health insurance altogether. They have thus brought this action to challenge the Secretary’s approval of Kentucky HEALTH.

Although the Secretary is afforded significant deference in his approval of pilot projects like Kentucky’s, his discretion does not insulate him entirely from judicial review. Such review reveals that the Secretary never adequately considered whether Kentucky HEALTH would in fact help the state furnish medical assistance to its citizens, a central objective of Medicaid. This signal omission renders his determination arbitrary and capricious. The Court, consequently, will vacate the approval of Kentucky’s project and remand the matter to HHS for further review.

The ruling included more specific details about the Kentucky HEALTH program:

  • Community -engagement requirement: which requires beneficiaries to spend at least 80 hours per month on qualifying activities (including employment, job-skills training, education, community service, and participation in SUD treatment) or lose their Medicaid coverage.
  • Limits on retroactive eligibility: which will excuse the state from “provide[ing] three months of retroactive eligibility for beneficiaries receiving coverage through the Kentucky HEALTH program; except for pregnant women and former foster care youth”
  • Monthly premiums: including premiums varied based on income and/or length of time enrolled in Medicaid;
  • Limits on non-emergency medical transportation: which “relieve Kentucky of the requirement to assure non-emergency medical transportation to and from providers for the new adult group” – i.e. adults without disabilities, except for those who are medically frail, former foster-care youth, or pregnant;
  • Reporting requirements: which mandate that individuals provide information for an annual redetermination and report changes in income or circumstances that affect Medicaid eligibility within 10 days; and
  • Lockouts: which allow the state to deny Medicaid coverage for up to six months for any beneficiary who (a) has income above 100% of the FPL and (b) failed to meet her premium or reporting requirements.

Other interesting parts of the ruling include:

…In this case, Plaintiffs accuse HHS of “take[ing] by regulatory fiat what it could not accomplish in Congress.”…The Secretary and Kentucky, they say, sought to do little more than “knock people off Medicaid and undermine the Medicaid expansion enacted by Congress.”… With that in mind, their nine-court Complaint – which relies almost exclusively on the APA – challenges nearly every component of Kentucky HEALTH…

…Considering all of its aspects, Plaintiff say Kentucky HEALTH might strip them of Medicaid coverage altogether. Generally, “an eligible recipient… ha[s] a concrete interest in Medicaid benefits.”…The D.C. Circuit had “no doubt,” for example, that agency actions “threaten[ed] an individual’s ability to obtain Medicaid coverage… satisf[ied] the injury element of constitutional standing…

…The Secretary does not dispute that any Plaintiffs subject to higher premiums would suffer a cognizable injury. Instead, he suggests that each named Plaintiff might be exempt from this requirement. Kentucky HEALTH, however, excepts only the following groups from premium payments: (1) former foster-care youth; (2) pregnant women; and (3) medically frail individuals. Although Kentucky has not yet defined medically frail, several Plaintiffs aver that they are “healthy and do not have any ongoing medical problems.”…

…CMS suggest that these Plaintiffs might nevertheless meet one of the other two exemptions… but the Court cannot agree. Quite obviously, Roode, a 39-year-old man, is not a pregnant woman. Medical advances notwithstanding, Kasey, a 56-year-old woman, is also unlikely to meet that criterion…. Plaintiffs also represent in their briefing that they will not “be exempted as former foster care youth.”

…The Court therefore finds it likely that at least two Plaintiffs would be required to pay increased premiums and thus would suffer a concrete injury from Kentucky HEALTH. This is all that is needed to challenge the program…

…Kentucky tries to muddy the waters, arguing that Plaintiffs cannot satisfy the repressibility prong because “if [they] prevail in this action, the Commonwealth will not continue participating in expanded Medicaid.”… While the Governor has indeed issues an Executive Order directing the Commonwealth to “unexpand” Medicaid if any aspect of Kentucky HEALTH is invalidated… that Order has no bearing on the standing analysis here. The Executive Order calls for the Commonwealth’s Medicaid agency “to take the necessary actions to terminate Kentucky’s Medicaid expansion program” only after a final court judgement… The EO cannot take effect before this Court’s decision. Even if Kentucky were able to “unexpand” Medicaid (far from a foregone conclusion), Plaintiffs would have, at a minimum, momentary relief….

…At bottom, the record shows that 95,000 people would lose Medicaid coverage, and yet, the Secretary paid no attention to that deprivation. Nor did he address how Kentucky HEALTH would otherwise help “furnish… medical assistance.” In other words, he glossed over “the impact of the state’s project” on the individuals whom Medicaid “was enacted to protect.”…By doing so, he “failed to consider adequately” a salient purpose of Medicaid, and, thus, an important aspect of the program. The Court, consequently, cannot validate his approval of Kentucky HEALTH…

…CONCLUSION

For the foregoing reasons, the Court will deny Defendants’ Motions for Summary Judgement. It will also grant Plaintiff’s Motion for Summary Judgement via Count VII, vacate the Secretary’s approval of Kentucky HEALTH, and remand to the agency. A contemporaneous Order to that effect will issue this day.

July 1, 2018: Forbes posted an article titled: “Trump’s Medicaid Work Rules Were Adding To Costs Even Before A Judge Blocked Them”. It was written by Bruce Japsen. From the article:

The Trump administration’s efforts to require Medicaid patients to work has already been adding to costs from a new layer of administrative bureaucracy that began even before a federal judge ruled against them in one state, insurers say.

U.S. District Judge James Boasberg said Trump’s health Secretary “never adequately considered whether Kentucky HEALTH would in fact furnish medical assistance to its citizens, a central objective of Medicaid.” Thus, that “omission renders his determination arbitrary and capricious.”

The ruling Friday not only puts in doubt the effort to implement Medicaid work requirements proposed earlier this year by the Trump administration and the Centers for Medicare & Medicaid Services (CMS) under Seema Verma. But the work requirement implementation continues to be a headache for health insurers that administer Medicaid benefits for low income Americans as the health plans predicted it would be…

…Prior to Trump and Verma, past administrations found work requirements “could undermine access to care and were thus inconsistent with the purposes of Medicaid,” background in the case says. In Kentucky, the work requirement added an annual reporting requirement and “redetermination” of eligibility as well as other rules patients, health plans and medical providers had to take into consideration when caring for patients.

If the new requirements are still pursued in Kentucky and elsewhere, providers and insurers predict patients could face gaps in care and cause Medicaid patients to avoid seeing a doctor, and get sicker down the road and end up costing taxpayers and the health system more money in the long run…

…With Medicaid work requirements, there’s a worry of an extra layer of burden to vet people who largely already have jobs. Studies show that most Medicaid beneficiaries are working and adding more paperwork could lead to unnecessary gaps in coverage…

July 2, 2018: The Hill posted an article titled: “Ky. governor cancels Medicaid dental, vision benefits after losing work requirement ruling”. It was written by Peter Sullivan. From the article:

Kentucky Gov. Matt Bevin’s (R) administration is canceling dental and vision benefits for thousands of people on Medicaid in the state following a judge blocking the state’s Medicaid work requirements.

The cancellation of dental and vision coverage for almost 500,000 enrollees in the state’s Medicaid expansion is “an unfortunate consequence of the judge’s ruling,” Doug Hogan, a spokesman for the Kentucky Cabinet for Health and Family Services, told the Louisville Courier-Journal.

Democrats denounced the move and said they did not think Bevin had the legal authority to cancel the benefits…

…Under Bevin’s Medicaid proposal, along with work requirements, enrollees would have had to earn dental and vision benefits through completing activities like taking classes or searching for a job.

With the proposal blocked in court, Bevin’s administration is now canceling dental and vision benefits altogether…

…Bevin has threatened to cancel the state’s Medicaid expansion altogether if the work requirements are struck down. Friday’s ruling can be appealed, though, so the issue is not fully resolved.

July 2, 2018: MHPA (Medicaid Health Plans of America) posted a statement titled: “Statement from Jeff M. Myers, president and CEO of Medicaid Health Plans of America, on the US District Court’s rejection of the Kentucky HEALTH waiver”. From the statement:

Today, U.S. District Judge James Boasberg rejected HHS Secretary Azar’s approval of the Kentucky HEALTH waiver that included not only Medicaid work requirements provisions, but other changes to the program as well.

MHPA shares the concerns raised by Judge Boasburg about how the proposal would affect Medicaid enrollees. Our member health plans in Kentucky and other states that have proposed work requirements have invested significant resources in an attempt to address these issues. However, the ruling now puts in limbo all of the state infrastructure to implement these measures that our plans have been building.

Furthermore, the states where work requirements, community engagement, co-pays, etc., were used to find legislative compromise now must perform a delicate balancing act to bring needed health care to hundreds of thousands of the working poor via state expansion. We encourage the prompt legal review of these issues to provide clarity and direction to all stakeholders.

We expect that the ruling will be appealed. In the meantime, we are committed to working with our state partners over the next several months to determine the best path forward.

July 6, 2018: Los Angeles Times posted an article titled: “South Carolina governor cuts healthcare to take antiabortion stand”. From the article:

South Carolina Gov. Henry McMaster removed $16 million for healthcare from the state budget, saying Friday he wanted to make sure no taxpayer money goes to abortion providers.

The Republican governor said he was keeping a promise he made repeatedly as he campaigns for a full term, disagreeing with Democrats and some Republicans who said Planned Parenthood gets less than $100,000 of the money and all of it goes for family planning and not abortion…

…Planned Parenthood said the veto is a “political stunt” and the practical effect will be to remove birth control, testing for sexually transmitted disease and even cancer screenings for hundreds of thousands of poor women on Medicaid…

…Republicans have been fighting over the “Family Planning” line in the budget for months. McMaster did not veto the entire $34 million in the item, with his office saying eliminating all that money would keep 700,000 women and children from getting prescriptions through Medicaid.

Democrats and Republicans – even those adamantly against abortions – called removing the money from the budget shortsighted because so little goes to Planned Parenthood in the first place and removing ti from the spending plan could mean less money for things like law enforcement or help for families with children with autism…

…McMaster said he would prefer if the federal government approves his request for a waiver that would allow South Carolina to withhold any public funds from Planned Parenthood, but his office does not know when that might be considered.

July 7, 2018: CMS (Centers for Medicare & Medicaid Services) posted a press release titled: “United States Court Ruling Puts Risk Adjustment On Hold”. From the press release:

On February 28, 2018, the United States District Court for the District of New Mexico issued a decision invalidating use of the statewide average premium by the Center for Medicare & Medicaid Services (CMS) in the risk adjustment transfer formula established under section 1343 of the Patient Protection and Affordable Care Act for the 2014 – 2018 benefit years. The ruling prevents CMS from making further collections or payments under the risk adjustment program, including amounts for the 2017 benefit year, until the litigation is resolved.

In light of a contrary decision by the United States District Court for the District of Massachusetts, the government moved the New Mexico district court to reconsider its decision, and CMS is currently awaiting the court’s ruling. CMS is seeking a quick resolution to the legal issue raised and will inform stakeholders of any update to the status of collections or payments at an appropriate future date. The calculated risk adjustment transfer amounts for the 2017 benefit year are $10.4 billion, which includes transfers across catastrophic, small group, and individual non-catostrophic risk pools…

…The New Mexico district court’s ruling bars CMS from collecting or making payments under the current methodology, which uses the statewide average premium. This aspect of the risk adjustment methodology was promulgated as part of a regulation first issued by the Obama Administration in 2013. CMS will provide additional guidance shortly on how it will handle other issues relating to risk adjustment payments, including EDGE server data collection operations, appeals of 2017 risk adjustment amounts, and how issuers should treat risk adjustment amounts in the calculation of medical loss ratios…

July 7, 2018: Protect Our Care posted a statement titled: “Protect Our Care Statement On Historic DOJ Health Care Sabotage”.  From the statement:

After a partisan team of Department of Justice lawyers decided to abandon the rule of law in order to help a lawsuit that could eliminate the Affordable Care Act overnight, Protect Our Care Campaign Director Brad Woodhouse made the following statement:

“The Trump Administration just made history by undermining the rules of law in order to continue its no-holds barred war on American health care. By abandoning its legal and constitutional responsibilities to defend the law of the land, Jeff Sessions’ Department of Justice is prioritizing a political vendetta over centuries of legal precedent. If Trump and Sessions have their way, the Affordable Care Act and Medicaid expansion will disappear overnight, stealing coverage from millions of Americans, winding back the clock on people with pre-existing conditions, and undermining the stability of the U.S. economy. Tonight, as the President and his Administration launch their most dangerous sabotage effort yet, we are seeing just how far Republicans are willing to go in their quest to undermine the American health care system. And by sowing even more uncertainty into the health care markets, tonight’s action could encourage insurance companies to propose even higher rate increases than the double-digit hikes already threatening to hit American families next year.”

July 7, 2018: BlueCross BlueShield posted a statement titled: “Blue Cross Blue Shield Association Statement on Risk Adjustment Payment Freeze.” From the statement:

The Blue Cross Blue Shield Association issued the following statement today from President and CEO Scott Serota:

“We are extremely disappointed that the administration has frozen payment transfers under the Affordable Care Act’s (ACA) risk adjustment program, which is designed to keep costs down for consumers while meeting the medical needs of those requiring significant care. Risk adjustment is a Congressionally-mandated program that supports both the individual and small group health insurance markets.

“Without a quick resolution to this matter, this action will significantly increase 2019  premiums for millions of individuals and small business owners and could result in far fewer health plan choices. It will undermine Americans’ access to affordable coverage, particularly for those who need medical care the most.

“CMS should use all legal avenues available to make the payments on schedule and should do so to protect consumers.

“Risk adjustment is a concept that has been long supported and embraced by both Republicans and Democrats through programs like Medicare Advantage. The Program does not cost taxpayers any money and has worked effectively to help balance the cost of caring for those with significant health need by ensuring that health plans are able to enroll all consumers, regardless of their health status.

“The actions taken today will create turmoil not only for the individual market – particularly as insurers finalize their offerings for the next open enrollment that begins in November – but also for the millions of businesses that rely on the small group market to provide affordable insurance options for their employees.

“Risk adjustment is a mandatory program under federal law. CMS should take immediate action to reinstate these payment transfers to ensure the market works as intended under the law and that coverage for millions of Americans is not disrupted.”

July 7, 2018: AHIP posted a statement titled: “AHIP Statement on the Freeze of Risk Adjustment Payments for the Individual and Small Group Markets.” From the statement:

America’s Health Insurance Plans (AHIP) issued the following statement following the Administration’s decision to freeze risk adjustment payments for the individual and small group markets, in light of the decision earlier this year by the United States District Court for the District of New Mexico:

“We all agree that Americans deserve affordable, comprehensive coverage and care – regardless of whether they are sick, healthy, or have a pre-existing condition. Because different plans cover different people, the health of the people they server differs as well. The risk adjustment program helps ensure coverage is available for high-need patients by sharing the cost of covering them. If a plan covers more patients who require more health care services, that plan receives funds from other plans that cover fewer high-ned patients – all without using any taxpayer dollars.”

“We are very discouraged by the new market disruption brought about by the decision to freeze risk adjustment payments. This decision comes at a critical time when insurance providers are developing premiums for 2019 and states are reviewing rates. This decision will have serious consequences for millions of consumers who get their coverage though small businesses or buy coverage on their own. It will create more market uncertainty and increase premiums for many health plans – putting a heavier burden on small businesses and consumers, and reducing coverage options. And costs for taxpayers will rise as the federal government spends more on premium subsidies.

“We agree that a quick resolution is needed to avoid greater harm to individual and small group markets. More than ever, American business and families want affordable coverage and care they need and deserve. We encourage the Administration to reevaluate its decision and work with all stakeholder to make health care more affordable for all Americans.”

July 8, 2018: NPR posted an article titled: “Trump Administration Freezes Payments Required By the Affordable Care Act”. It was written by Maggie Penman. From the article:

The Trump administration said Saturday that it is temporarily halting billions of dollars in payments designed to help insurers meet the Affordable Care Act requirement that they provide coverage regardless of whether a person is healthy or sick.

The administration said it was withholding $10.4 billion in the so-called “risk adjustment” payments, citing a district court ruling from earlier this year in New Mexico. While the administration says it is required to stop payments because of the court decision, insurers say the move could result in higher premiums for millions of individuals and small businesses…

…The New Mexico ruling fond fault with the formula the government used to calculate the payments, saying it was “arbitrary and capricious”. But another district court in Massachusetts upheld the formula.

The announcement came as insurers were awaiting an annual report that usually comes at the end of June, informing them of whether they owe money into the risk adjustment program or will be paid out for the previous year. Insurers say the sudden halting of those payments creates uncertainty at a critical time, as they are currently developing their premiums for 2019…

…”Insurers hate uncertainty, and when faced with it tend to raise premiums to hedge their bets,” says Larry Levitt, Senior Vice President at the Kaiser Family Foundation. He says halting the risk adjustment program will disrupt the individual markets, and might even cause insurers not to participate next year.

“When the rules of the game chance after the fact – insurers don’t necessarily see the federal government as a particularly reliable partner right now,” Levitt says. “This is one of several steps the Trump administration has taken to undermine the ACA.”…

July 10, 2018: Slate posted an article titled: “Trump’s Office of Refugee Resettlement Is Budgeting for a Surge in Child Separations”. It was written by Mark Joseph Stern. From the article:

…There are currently about 11,800 children in ORR’s (Office of Refugee Resettlement) care. Alex Azar, the secretary of the Department of Health and Human Services, has started that somewhere between 2,000 and 3,000 of those children were separated from their parents at the border. The remaining children in ORR custody are unaccompanied minors – children who crossed the border without a parent or guardian.

In the documents obtained by Slate, ORR officials describe the budget implications of a potential surge in immigrant minors over the next three months. The ORR’s budgeting exercise is premised on the possibility that the agency could need as many as 25,400 beds for immigrant minors by the end of the calendar year. The documents do not indicate that ORR officials have specific knowledge that family separations will increase but do show that the agency is preparing for the possibility.

The internal documents estimate that if 25,400 beds are needed, ORR would face a budget shortfall of $585 million for ORR for fiscal year 2018, which ends on Sept. 30. Under this scenario, that shortfall would increase to $1.3 billion in the first quarter of fiscal year 2019, adding up to a total shortfall of $1.9 billion for the period between Oct. 1, 2017, and Dec. 31, 2018. The documents stress that these budget estimates represent maximum possible expenditures and that actual expenses may be lower. The Department of Health and Human Services did not respond to multiple requests for comment about these figures or anything else relating to the documents,

To help cover potential costs, the documents say, HHS will seek supplemental appropriations from Congress. The documents also indicate that HHS plans to pay for child separation by reallocating money from the Ryan White HIV/AIDS Program, which, according to its website “provides a comprehensive system of care that includes primary medical care and essential support services for people living with HIV who are uninsured or underinsured.” Per the documents, the process of transferring those HIV/AIDS funds has already begun…

July 12, 2018: The New York Times posted an article titled “Fact Check of the Day: Democrats Overstate Kavanaugh’s Writings on the Affordable Care Act”. It was written by Linda Qiu.  The article starts with quotes from three Democratic Senators, and states that their comments are exaggerated. This is followed by a fact check.

The reason this is noteworthy is because Justice Anthony Kennedy retired from the Supreme Court of the United States – giving President Trump a second opportunity to nominate someone to fill that seat. Trump selected Judge Brett M. Kavanaugh, who would have to go through at least one hearing, and a favorable vote by the full Senate, before he can join the Supreme Court.

…Judge Kavanaugh has written two dissenting opinions in the legal challenges to the Affordable Care Act while serving on the United States Court of Appeals for the District of Columbia Circuit.

In both cases, he refrained from making broad pronouncements about the constitutionality of the Affordable Care Act, said Wendy Parmet, a professor of health law at Northeastern University.

She characterized one dissent as “very boring, technical, very arcane” and the other as “very technical, lawyerly, and boring.”

Nicholas Bagley, a professor of health law and administrative law at the University of Michigan disagreed with the Democrats’ framing of Judge Kavanaugh’s writings. He said Judge Kavanaugh “doesn’t think of these cases as Affordable Care Act cases” but instead focuses on specific legal issues…

The article then looks at three Affordable Care Act related cases in which Judge Kavanaugh was involved.

…Seven-Sky v. Holder: In 2011, Judge Kavanaugh’s appeals court upheld the Affordable Care Act’s individual mandate that compelled most Americans who do not have health insurance to pay a penalty. (The tax law signed by President Trump in December repealed the mandate, effective 2019.)

In his dissent, Judge Kavanaugh argued that the court should not have heard the case in the fist place, since the Anti-Injunction Act of 1867 forbids judges to rule on tax cases until the tax has already been collected. The individual health care mandate did not take effect until 2014 so, he wrote, plaintiffs sued prematurely and “the Anti-Injunction Act precludes us from deciding this case at this time.”…

…”I do not take a position here on whether the statute as currently written is justifiable under the Taxing Clause or the Commerce Clause,” Judge Kavanaugh wrote. “What I am saying is that the only potential Taxing Clause shortcoming in the current individual mandate provision appears to be relatively slight.”…

…Sissel v. Department of Health and Human Services: In 2015, taxpayers challenged the Affordable Care Act on grounds that it violated the Constitution because revenue-raising bills must originate from the House of Representatives under the Origination Clause.

This appeals court rejected the challenge, ruling that the clause did not apply because the law’s primary purpose was to expand health care, not to raise revenue. Judge Kavanaugh again wrote the dissenting opinion which argued that although the health law is a revenue-raising bill, it “did in fact originate in the House, as required by the clause.”…

July 12, 2018: The Hill posted an article titled: “Trump health chief defense suspending ObamaCare payments.” It was written by Nathaniel Weixel. From the article:

The Trump administration is bound by a federal court decision to suspend billions of dollars in ObamaCare payments, Centers for Medicare and Medicaid Services (CMS) Administrator Seema Verma said Thursday…

…In a surprise announcement last week, the administration said it had suspended $10.4 billion in “risk adjustment” funding that is supposed to be paid to insurers to help them provide coverage to particularly sick and costly enrollees…

…A federal court ruling in New Mexico found the administration did not properly justify its formula for dispensing the funds. Varma said the administration is defending the risk adjustment regulation, even though it was written under the Obama administration.

Verma said CMS is asking the court to reconsider, but until that happens, the agency’s hands are tied…

…Legal experts have expressed skepticism that the administration is doing everything it can to fix the problem.

Some have said CMS is being deliberately disruptive because of its hostility to ObamaCare, and that government programs should not be at the mercy of a lone federal judge.

But at the same time, Verma would not say if the administration plans to stop approving state Medicaid work requirement waivers…

July 12, 2018: The Hill posted an article titled: “House panel advances bill that would temporarily halt ObamaCare’s employer mandate”. It was written by Jessie Hellmann. From the article:

The House Ways and Means Committee on Thursday approved legislation that would chip away at ObamaCare, including a measure that would temporarily repeal the law’s employer mandate.

The bill sponsored by GOP Reps. Devin Nunes (Calif.) and Mike Kelly (R- Pa.) would suspend penalties for the employer mandate for 2015 through 2019 and delay implementation of the tax on high-cost employer-sponsored health plans for another year, pushing it back to 2022.

Congress repealed the penalty associated with the individual mandate last year, but it doesn’t take effect until 2019…

…Powerful lobbying groups like the U.S. Chamber of Commerce have pushed for a repeal of the employer mandate.

The other measure, sponsored by Reps. Peter Roskam (R.-Ill.) and Michael Burgess (R-Texas), would allow the use of ObamaCare’s tax credits for plans outside of the exchanges in the individual market. It would also allow anyone to purchase a catastrophic plan – plans that are cheaper but cover fewer services and are currently only available for those under the age of 30….

…Both measures advanced on party-line votes.

Democrats opposed the bills, saying they would cost too much and destabilize ObamaCare.

July 13, 2018: Vox posted an article titled: “How the slow sabotage of Obamacare may hurt America’s breast-feeding rate”. It was written by Julia Belluz.

…the Affordable Care Act (ACA), also known as Obamacare, included provisions aimed at supporting mothers who want to breastfeed, as part of its expansion of preventative-health services coverage. The regulations – and how they are applies by companies – haven’t been perfect, and some women have fallen through the cracks.

But in recent years, several studies have shown that the provisions – giving moms access to lactation consultants, breast pumps, and time and space at work to pump their milk until as late as a year after birth – have contributed to rising breastfeeding rates in the US.

The ACA’s regulations went into effect in 2010 and 2012. From 2011 to 2014, the rate of women who were breastfeeding 12 months after giving birth rose from 27 percent to 34 percent, according to the Centers for Disease Control and Prevention. That amounted to the largest increase in any recent three-year period.

Now, women’s health and breastfeeding advocates worry that we  might be poised for a reversal of this trend.

The news that the administration of President Donald Trump undermined breastfeeding at a United Nations global health meeting and aligned itself with the $70 billion baby formula industry has sent a powerful signal that expanding breastfeeding access won’t be a priority for his administration…

…In addition, the administration’s focus on sabotaging the ACA doesn’t bode well for breastfeeding rates. It means that fewer people will access health care and insurance companies can now sell skimpier, short-term plans with few benefits and protections (such as coverage for preventative services like breastfeeding support.)…

…Section 2713 of the law [the ACA] requires health insurance plans to provide coverage for breastfeeding support (like lactation counseling) and supplies (such as breast pumps) without any co-payments, deductibles, or co-insurance, as long as a woman opts for breastfeeding. This coverage is required for employer-sponsored plans, individual plans purchased through the Obamacare marketplaces, and for Medicaid enrollees who access public coverage through the ACA’s Medicaid expansion.

Section 4207 of the ACA also requires that companies with annual sales of more than $500,000 provide break times and a private place (not including a bathroom) where moms can use breast pumps to express their milk at work…

…Mara Gandal-Powers, of the Women’s Health Law Center, explained that these stories [of women whose health insurance companies refused to cover lactation consulting] are not uncommon. Because lactation consulting is a service that women need immediately after birth, they’re not typically in a position to haggle with insurance companies over coverage. “If you don’t get the services to help you increase your [breast milk] supply quickly, nursing can become difficult or impossible and not really happen. So we see women who pay out of pocket.”

Instead of working to fix these gaps in coverage, the Trump administration has been attempting to dismantle the ACA. And while Republicans have failed to fully repeal the law, they’ve put forward a series of policies that have caused the uninsured rate to rise and have weakened the law in the process…

…Breastfeeding is a “preventative service,” said Kaiser’s Salganicoff. “So if its a short-term plan, it doesn’t have to have maternity care, preventative services and women who enroll in the plans would not have the entitlement to the breastfeeding coverage.”

July 13, 2018: Press of Atlantic City posted an article titled “N.J. extends 2019 Obamacare rates deadline amid federal shakeups”. It was written by Nicole Leonard.  From the article:

…State insurers are expected this month to determine how much residents who get health care coverage through the ACA should pay for their plans in 2019, but a recent disruption by President Donald Trump’s administration on payments that have helped stabilize the market is causing delays.

The White House announced earlier this month that billions of dollars in federal payments under the ACA’s risk-adjustment program will be put on hold…

…The freeze on the payments comes at a crucial time when insurers try to calculate what they should charge customers next year. Nearly 275,000 New Jersey residents selected Obamacare plans on the federal exchange during last year’s enrollment period, according to the U.S. Centers for Medicare and Medicaid…

…In response to the federal announcement, New Jersey Department of Banking and Insurance officials said they extended the deadline for insurers to file ACA plan rates by another week to July 18 because the decision to halt adjustment payments came just days before the state’s original deadline of July 11…

…The state’s insurance department told New Jersey Obamacare insurers, which this year included Horizon BlueCross BlueShield of New Jersey, AmeriHealth and Oscar, in a July 9 memo that they should calculate their plan rates, or premium prices, assuming the risk-adjustment payments will resume…

…State officials said final ACA plan rates are expected to be finalized and released by the end of the summer ahead of open enrollment, which begins Nov. 1.

July 13, 2018: Nashville Patch posted an article titled: “Tennessee Obamacare Insurers Cutting Premiums”. It was written by J. R. Lind. From the article:

For the first time, Tennesseans with coverage through the health-insurance exchanges set up by the Affordable Care Act will see their premiums go down.

According to state regulatory filings, Cigna plans to reduce premiums for its individual plans by an average of 4.8 percent and BlueCross BlueShield of Tennessee will slash its average rate by 10.9 percent.

Both Cigna and BCBST increased premiums by double digits the last four years.

Oscar, the only other company offering individual plans in Tennessee, requested a 10.8 percent premium increase…

July 16, 2018: Pacific Standard posted an article titled: “After a Report Criticizing Obamacare Removals From Medicaid.Gov Starts to Circulate, The Law Gets A Boost on Medicaid’s History Page.”  It was written by France Diep. From the article:

After a government transparency group tried to alert the Centers for Medicare and Medicaid Services (CMS) of an upcoming report, – which showed that a bank of webpages about Obamacare had been pulled from Medicaid.gov – a fresh batch of Obamacare information appeared in a prominent place on the site. At the bottom of Medicaid.gov’s “Program History” page, there’s now a table breaking down the numerous ways that the Affordable Care Act has affected Medicaid, expanding the number of Americans who are eligible and improving its benefits.

…But a spokesman for CMS said that the update is a coincidence…

…Pacific Standard noticed the update after reporting on work from the Sunlight Foundation’s Web Integrity Project, which uses software to track tens of thousands of .gov webpages. Web Integrity Project Director Toly Rinberg says a staffer sent out inquiries to CMS in the afternoon on July 9th, and on July 11th.

The project’s software shows the “Program History” page did not contain the Affordable Care Act table on the morning of July 9th; Google’s caching shows that, by the early morning hours of July 10th, it did. The table contains all the sections that had previously appeared on an Affordable Care Act landing page that was removed from Medicaid.gov in June.

July 19, 2018: WLKY posted an article titled: “Reversal: Kentucky restoring Medicaid benefits for thousands.” From the article:

Kentucky Gov. Bevin’s administration says it’s reinstating dental and vision care for hundreds of thousands of Medicaid recipients who had their benefits cut recently amid an outcry.

The benefits were abruptly cut after a federal judge rejected the Republican governor’s plan to overhaul Kentucky’s Medicaid program. The cuts triggered stinging criticism from Democrats and public health advocates.

The reversal was announced late Thursday by the state’s Cabinet for Health and Family Services. It says dental and vision coverage are being restored to “mitigate the consequences” of the ruling.

The ruling marked a setback for President Donald Trump’s administration, which has been encouraging states to impose work requirements and other changes on the state and federal health insurance program for poor and disabled people.

The ruling blocks those requirements for now in Kentucky.

July 19, 2018: The New York Times posted an 0pinion piece titled: “Want Reliable Medical Information? The Trump Administration Doesn’t”. It was written by The Editorial Board of The New York Times.  From the Opinion piece:

…On Monday, the Department of Health and Human Services took it [The National Guideline Clearinghouse] offline, the latest casualty in an administration determined to eliminate science from the government’s agenda.

The official explanation is maddening enough: a budget shortfall that roughly equals the amount Tom Price spent on travel during his brief tenure as department secretary. The site costs just $1.2 million a year to operate, and is maintained by an agency with a budget of more than $300 million.

But the more complete explanation – involving political discord over the site’s parent agency and sustained indifference on the part of the doctors and patents – should concern anyone worried about the state of American health care.

The clearinghouse was created in the 1990s as part of a wider movement to better link the practice of medicine to sound scientific research. It has been in danger of disappearing almost since the start.

Republicans argue that the database is redundant with other programs. But in some cases, other motivations for eliminating it have been all too clear. In the late 1990s, when it endorsed nonsurgical interventions for back pain, the back surgeon lobby waged an attack that resulted in huge funding cuts and placed a permanent target on the Agency for Healthcare Research and Quality (A.H.R.Q.), the agency that houses the database.

Since then, A.H.R.Q. has survived numerous attempts on its life, most recently in 2017, when the Trump administration proposed folding it into the National Institutes of Health. To its credit, Congress rejected that proposal, and instead gave the agency a $10 million bump. But the increase was not enough to undo the damage done by all the previous years’ cuts. Adjusted for inflation, A.H.R.Q. has lost about $120 million in funding since 2010…

…Budget cuts are not the only problem, though. The clearinghouse gets about 200,000 visitors a month, and professional medical societies have protested the database’s closing. But many individual doctors have greeted the news with a shrug, saying they only rarely visit the site anyway. And most consumers have no idea what the database is, or why it matters.

That’s too bad. America spends around $3.5 trillion a year on health care, and more than $30 billion on biomedical research. But we have made very little effort to link the two. In fact, studies indicate that the care we receive is not based on any sound scientific evidence; we receive only about half of the care we do need, and a lot of care that doesn’t benefit us at all. The clearinghouse, were it better utilized, could help solve this problem, and in doing so, could improve patient outcomes and reduce health care costs…

…A better solution would almost certainly be for Congress to appropriate the money needed to keep the database up and running. It could do that simply by renewing the Affordable Care Act fund that was covering the database’s operating costs, and that is scheduled to expire in 2019…

July 19, 2018: Bloomberg posted an article titled: “Trump Administration Preparing Fix for Obamacare Risk Payments”. It was written by Zachary Tracer. From the article:

The Trump administration is preparing a regulation that would allow the resumption of billions of dollars in payments to health insurers in Obamacare.

The Office of Management and Budget was sent a rule on Wednesday from the Centers for Medicare and Medicaid Services tied to the risk-adjustment program, which transfers money to insurers who take on sicker customers.

An administration official said the rule is an option being considered to resolve the legal dispute that has held up the payments.

The rule is labeled as an interim final rule, a status that would allow it to go into effect immediately. It’s titled “Ratification and Resistance of the Methodology for the HHS-operated Permanent Risk Adjustment Program under the Patient Protection and Affordable Care Act.”…

…Health-insurance industry groups had pushed the Trump administration to issue a interim final rule for the risk-adjustment program to resolve a legal dispute that had threatened to halt payments under the program. The risk-adjustment payments, worth $10.4 billion for 2017, are part of a program in the Affordable Care Act meant to help balance the insurance markets when some insurers inevitably got stuck with costlier patients…

July 19, 2018: Sunlight Foundation posted a blog post titled: “HHS removes sex discrimination prohibition language from civil rights office website.” It was written by Rachel Bergman and Jon Campbell. From the article:

The Department of Health and Human Services’ Office for Civil Rights has altered messaging on its website related to Section 1557, the provision of the Affordable Care Act prohibiting discrimination, including sex discrimination. Advocates and experts say the changes to informational webpages about Section 1557, detailed in the latest Web Integrity report, could foreshadow a shift in policy regarding the prohibition of sex discrimination as the Department of Health and Human Services (HHS) prepares to release new regulations as soon as this month…

…Section 1557 has been the focus of a long-running legal battle of whether OCR [the Office for Civil Rights], the office responsible for enforcing regulations stemming from 1557, can respond to complaints of discrimination against transgender and gender nonconforming individuals. HHS had determined that the text of Section 1557 allowed it to prohibit all forms of sex discrimination, including discrimination based on an individual’s sex, pregnancy, gender identity, and sex stereotyping, and it put in place these Section 1557 regulations to do so.

HHS’s ability to implement Section 1557 regulations, however, was limited after a lawsuit by religiously affiliated healthcare providers argued that they would “require them to perform and provide insurance coverage for gender transitions and abortions,” according to court records. In December of 2016, the federal court in Texas hearing the case issues a nationwide preliminary injunction that prevents OCR from enforcing Section 1557 protections against discrimination baed on gender identity and termination of pregnancy, without affecting protections from other forms of sex discrimination.

The lawsuit is ongoing, but experts told WIP that the documented changes to OCR website seem to go well beyond what the injunction requires. First, language on the OCR webpages about Section 1557 has been removed such tat, while the pages do still refer to sex discrimination on the basis of an individual’s sex and pregnancy, they no longer explicitly state that sex stereotyping and discrimination on the basis of gender identity are prohibited. Second, after language was added to the webpages to explain the outcome of an injunction, some of the language was later removed that explicitly stated that, even with the injunction in place, OCR can still enforce prohibitions on sex stereotyping and discrimination on the basis of one’s sex…

…Additionally, the website, after being changed, now simply states that OCR “will continue to enforce… sex discrimination provisions that are not impacted by the court’s order.” The court has not enjoined OCR from enforcing the Section 1557 regulations’ prohibition on sex stereotyping, as [Kelli] Garcia [director of the Reproductive Justice Initiative at National Women’s Law Center] pointed out, but, without a stated definition of sex discrimination and an explicit statement about which provisions are not impacted by the injunction, OCR is not making clear to the public that it still has that power…

…On June 25, HHS filed a status update to the Texas court, stating that it is “reevaluating the reasonableness, necessity, and efficacy of the Rule that is challenged in this case” and asking the court to maintain the injunction. The rule being suggested by the HHS in the update, which might roll back all or part of the current 1557 regulations, won’t be made public until after its publication in the Federal Register, at which point HHS will begin accepting public comment…

July 19, 2018: The Press Democrat posted an article titled: “California ‘Obamacare’ premiums to rise 8.7 percent in 2019”. It was written by Jonathan J. Cooper.

Monthly health insurance premiums sold under former President Barack Obama’s health care law will rise by an average of 8.7 percent in 2019, less than the double-digit increases seen in the past two years and in other states.

The boost would be closer to 5 percent if not for the decision by Congress and President Donald Trump to eliminate the penalty for people who don’t carry insurance coverage, said Peter Lee, Covered California’s executive director. The penalty was credited with keeping rates down by driving healthier people into the market, but critics say nobody should be forced to buy a health plan…

…Covered California customers who get federal tax credits to lower their monthly premiums will be shielded from all or part of the higher costs because their subsidies will rise in tandem. But the higher prices will be felt by more than 1 million Californians who have unsubsidized coverage in the individual market, whether they get their plans through Covered California or not…

…Unsubsidized premiums in the individual market will be an average of $547 next year, up from $373 in 2014 when Obama’s health care law took effect. Actual premiums vary significantly across the state, with people in Southern California generally paying less than those in the North.

Covered California projects about 250,000 people in the individual market will drop their health coverage next year because they’ll no-longer pay a penalty…

July 19, 2018: Two Democratic Senators on the U.S. House of Representatives Committee on Energy and Commerce sent a letter to U.S. Department of Health and Human Services Secretary Alex. M. Azar and the Administrator for Medicare & Medicaid Services, Seema Verma.

The two Democratic Representatives were Ranking Member Frank Pallone, Jr. (Democrat – New Jersey) and Vice Ranking Member Kathy Castor (Democrat – Florida). From the letter:

We write to you with serious concerns regarding the Trump Administration’s intentional effort to end assistance for consumers shopping for affordable health care options, specifically authorized in the Affordable Care Act (ACA). Given the Administration’s repeated attempts to sabotage the ACA at the expense of consumers across the nation, the practical elimination of Navigators constitutes another costly blow to consumer simply for partisan gain. This lates effort to undermine the ACA ahead of the upcoming 2019 open enrollment period will further contribute to rising premiums and make it more difficult for millions of consumers across the country to access high-quality, affordable health insurance.

Navigators empower community nonprofits and health care organizations to provide in-person assistance to consumers with Marketplace enrollment. Under federal law, Navigators are tasked with a number of Marketplace enrollment responsibilities that are critical in reducing the uninsured rate. Navigators conduct public education activities to raise awareness of qualified health plan availability and are responsible for the distribution of “fair and impartial information” on enrollment and financial assistance.

The statue requires that Navigators “provide information in a manner that is culturally and linguistically appropriate to the needs of the population being served by the Exchange or Exchanges,” which means that Navigators, by law, are required to perform targeted outreach to individuals in communities that may experience difficultly with enrollment, such as those with language barriers or those without access to the Internet. In addition, Navigators serve as valuable resources for enrollees seeking to better understand their coverage, and many enrollees rely on Navigators for assistance even after they have signed up for coverage. For instance, Navigators also assist enrollees with appealing claims denials.

This year, CMS slashed funding for Navigators to $10 million – an 84 percent cut in funding from the $63 million awarded to Navigators during the final years of the Obama Administration. Last year, abruptly cuts to funding prompted some Navigators to shut down completely. This year, Trump Administration cuts to the Navigator program once again threaten the ability of Navigators to perform their crucial work. Per the Funding Opportunity Announcement (FOA), numerous states, such as North Dakota and West Virginia, are eligible for only $100,000 in Navigator funding. In response to these funding cuts, numerous Navigators are sounding the alarm…

…In addition to making deep cuts to the Navigator program, the Centers for Medicare & Medicaid Services (CMS) stipulates that funding awards will be based on Navigator performance from previous year. According to CMS, “accomplishments” constitute ten percent of the criteria that will be used to evaluate a Navigator’s funding application to “ensure accountability with the program.” However, it remains unclear what methodology CMS will employ to evaluate these “accomplishments”.

Furthermore, the Administration is promoting the use of junk plans, as opposed to solely encouraging enrollment in qualified health plans (QHPs). According to CMS, Navigators will be “encouraged to demonstrate how they provide information” on associated health plans (AHPs) and short-term, limited-duration insurance (STLDI). The Administration appears to tie Navigator funding to the promotion of junk plans by evaluating funding applications on a Navigator’s ability to establish relationships with “left behind” individuals who “may be unaware of the range of available options in addition to qualified health plans (QHPs), such as association health plans [and] short-term, limited-duration insurance.” These junk plans, which are not required to cover the Essential Health Benefits or include protections for people with preexisting health conditions, will not only leave consumers saddled with more medical debt, but will also raise premiums for individuals in the ACA-compliant market. That the Trump Administration continues in its attempts to promote junk plans over high-quality insurance and raise premiums for people with preexisting conditions further draws into question the President’s commitment to enforcing the law of the land and preserving the well-being of the American people.

We remain committed to ensuring that consumers across the country are able to access high-quality, affordable health insurance, despite repeated efforts by the Trump Administration and congressional Republicans to sabotage the ACA. In addition, we are deeply concerned that the Trump Administration is not making adequate preparations for the upcoming 2019 enrollment period. Therefore, we request responses to the following by August 2, 2018:

Here is a list of the questions that the two Democratic Representatives want responses to:

Please provide an explanation of how the Department arrived at the $10 million funding level, as well as an explanation of how the Department expects Navigators to fulfill the wide breadth of responsibilities legally required… at the $10 million funding level.

  • At this funding level, how will Navigators be able to fulfill their legally mandated responsibility to “conduct public education activities to raise awareness of the availability of qualified health plans?”
  • At this funding level, how will Navigators be able to fulfill their legally mandated responsibility to “distribute fair and impartial information concerning enrollment in qualified health plans, and the availability of premium tax credits…and cost sharing reductions?
  • At this funding level, how will Navigators be able to fulfill their legally mandated responsibility to “provide information that is culturally and linguistically appropriate to the needs of the population being served by the Exchange or Exchanges?

CMS Claims in the FOA that the decision to slash funding for the Navigator program was based on the percent of people Navigators enrolled in QHPs, as well as a comparison of the average cost for a Navigator to assist an enrollee against that for agents and brokers. Please provide teh underlying data used to arrive at these conclusions.

Please explain why Navigator funding period was reduced from three years – as was the case in the previous grant period – to one year. Please provide all communications pertaining to this decision. Such communications should include, but not be limited to, emails, letters, faxes, and any other written materials, as well as a list of any meetings, calls, or other oral communications, please include the date, time, and location at which such communication took place, as well as a list of individuals who participated.

Given that 42 U.S.C. 18031 stipulates that Navigator responsibilities pertain to QHPs, please explain why the criteria used to evaluate a Navigator’s grant applications for this funding period includes its ability to promote plans that do not satisfy consumer protections required under the ACA.

Please provide a detailed explanation of how Navigators’ performance in previous years will be evaluated as part of the “Accomplishments” criteria for scoring applications. As part of this explanation, please specify which metrics will be used to quantify and evaluate past performance, and what process will be used to review applications.

How does the Department intend to use the funds slashed from the Navigator program this year? Please provide an itemized list of how these funds will be used, including whether any of these funds will be directed to activities that promote enrollment in AHPs and STLDI, as well as enrollment through agents and brokers.

How did the Department use the funds diverted from the Navigator program last August? Please provide an itemized list of how these funds were used.

Please provide all analyses conducted by the Department to determine the impact that reductions to Navigator funding will have on the upcoming enrollment period, as well as any analysis conducted by the Department to determine the impact that last year’s funding cuts had on enrollment during the 2018 open enrollment period.

Please provide a justification for the Navigator funding distribution methodology implemented last year.

Please provide all self-reported performance data by current Navigators for the 2016-2017 year and for the 2017-2018 year.

July 19, 2018: The Hill posted an article titled: “House Dems want answers on cuts to ObamaCare outreach groups”. It was written by Nathaniel Weixel. From the article:

A pair of House Democrats want answers from the Trump administration about the decision to significantly slash funding for outreach groups that help people enroll in ObamaCare coverage.

The funding will be cut from $36 million this year to $10 million in 2019, the Centers for Medicare and Medicaid Services (CMS) said last week.

The administration’s funding for such outreach had already been slashed last year to well below the $63 million budgeted annually under former President Obama.

In a letter to CMS Administrator Seema Verma and Health and Human Services (HHS) Secretary Alex Azar, Democrat Reps. Frank Pallone Jr. (N.J.) and Kathy Castor (Fla.) asked the agencies to explain how they arrived at the $10 million funding level…

…They also asked Verma and Azar how the agencies expect the groups, known as navigators, to fulfill all the responsibilities legally required of them with only $10 million in funding…

…They also asked how the HHS plans to use the money that was saved from reducing Navigator funding….

July 24, 2018: The U.S. House of Representatives voted on H.R. 184 “Protect Medical Innovation Act”. The vote was 283 YEAS to 132 NAYS. This means that H.R. 184 passed the House of Representatives. Next, it will be sent to the U.S. Senate.

  • 226 Republicans voted YEA
  • 1 Republican voted NAY
  • 57 Democrats voted YEA
  • 131 Democrats voted NAY
  • 13 Representatives did not vote at all. Out of that number, 8 were Republicans and 5 were Democrats

The summary of H.R. 184 says:

This bill amends the Internal Revenue Code to repeal the excise tax on the sale of a medical device by the manufacturer, producer, or importer.

July 24, 2018: The Hill posted an article titled: “House votes to repeal ObamaCare medical device tax”. It was written by Peter Sullivan. From the article:

The House on Tuesday voted to repeal ObamaCare’s medical device tax, a provision that members of both parties have criticized as harming innovation.

The House voted 283 to 132 to repeal the 2.3 percent tax on sales of medical devices, with some Democrats joining Republicans to approve the measure. 57 Democrats voted for the measure.

The vote comes during a week of health-care measures put forward by the GOP as they try to blunt Democratic attacks over rising premiums, a key midterm message…

…There is no clear path forward for the measure in the Senate this year, however.

The tax has already been delayed twice, but this bill would permanently repeal it, which backers say is needed to give certainty to industry.

Some Democrats opposed repeal of the tax, though, pointing out it would deprive the government of about $20 billion over 10 years and that repeal of the tax is not paid for…

July 24, 2018: The Centers for Medicare and Medicaid Services (CMS) Department of Health and Human Services (HHS)  issued a document that had not yet been published on the Federal Register. This means there could be some changes made to the document when it is published on the Federal Register. The wording of the document that is placed on the Federal Register (whenever that may be) will be the official HHS-approved document.

This document is about the “Adoption of the Methodology for the HHS-operated Permanent Risk Adjustment Program under the Patient Protection and Affordable Care Act for the 2017 Benefit Year.” From the document:

This action of this document is described as: “Final Rule”.  From the Summary of the Final Rule:

This final rule adopts the risk adjustment methodology that HHS previously established for the 2017 benefit year. Section 1343 of the Patient Protection and Affordable Care Act (PPACA) established a permanent annual risk adjustment program under which payments are collected from health insurance issuers that enroll relatively low-risk populations, and payments are made to health insurers that enroll relatively higher risk populations. HHS sets the risk adjustment methodology in advance of each benefit year through a notice-and-comment rulemaking process. HHS sets the parameters ahead of the applicable benefit year so that insurers are able to rely on the methodology in pricing their plans.

In February of 2018, a district court vacated the use of statewide average premium as a basis for HHS-operated risk adjustment methodology for the 2014, 2015, 2016, 2017, and 2018 benefit years on the grounds that HHS did not adequately explain its decision to adopt a methodology that ensures that amounts collected from issuers equal payments made to issuers for the applicable benefit year (New Mexico Health Connections v. United States Department of Health and Human Services et all….).

The government’s motion for reconsideration of the ruling remains pending with the district court. Absent this administrative action, HHS would be unable in the coming months to collect charges or make payments to issuers for the 2017 benefit year. These amounts total billions of dollars, and failure to make the payments in a timely manner threatens to undermine the stability of the insurance markets, as issuers are now in the process of determining the extent of their market participation and the rates and terms of plans they will offer for the 2019 benefit year.

We hereby adopt the rules set out in the Federal Register on March 23, 2012 and the rules set out in the publication in the Federal Register on March 23, 2012 and the publications in the Federal Register on March 8, 2016…

July 24, 2018: Nicolas Bagley (University of Michigan Law Professor) posted a tweet on his verified Twitter account: “The new rule doesn’t make any substantive changes. It just offers the additional explanation that the court said it was looking for.” This tweet included an image of some of the text from the “Final Rule”:

…This final rule adopts HHS-operated risk adjustment methodology previously published at 81 FR 12204 for the 2017 benefit year with an additional explanation regarding the use of statewide premium and the budget neutral nature of the program. This rule does not make any changes to the previously published HHS-operated risk adjustment methodology for the benefit year…

This was followed by another tweet:”The tl;dr explanation is pretty straightforward. If you want risk adjustment to discourage insurers from competing over how well they discourage unhealthy people from signing up, you’ve got to make it budget neutral.”  This tweet includes another image of some of the text from the “Final Rule”:

…In light of the budget-neutral framework discussed above, HHS also chose not to use a different parameter for the payment transfer formula under the HHS-operated methodology, such as each plan’s own premium, that would not have automatically achieved equality between risk adjustment payments and charges in each benefit year. As set forth in prior discussions, use of the plan’s own premium or some similar parameter would have required the application of a balancing adjustment in light of the program’s budget neutrality – either reducing payments to issuers owed a payment, increasing charges on issuers due a charge, or splitting the difference in some fashion between issuers owed payments and issues assessed charges. Such adjustments would have impaired the risk adjustment program’s goals, discussed above, of encouraging insurers to rate for the average risk pool and avoiding the creation of incentives for issuers to operate less efficiently, set higher prices, develop benefit designs or create marketing strategies to avoid higher-risk enrollees…

This was followed by another tweet: “Plus, making the program dependent on annual appropriations from Congress isn’t exactly good for market stability.” This tweet include another image of some of the text of the “Final Rule”:

…Furthermore, if HHS had elected to adopt a HHS-operated risk adjustment methodology that was contingent on appropriations from Congress in the annual appropriations process that would have created uncertainty for insurers in the amount of risk adjustment payments they could expect. That uncertainty would undermine one of the central objectives of the risk adjustment program, which is to assure insurers that they will receive risk adjustment payments if, for the applicable benefit year, they enroll a high risk population compared to other issuers in the state market risk pool…

July 25, 2018: Politico posted an article titled: “Risk adjustment is back”. It was written by Sarah Kaelin-Smith, Renuka Rayasam and Dan Diamond. From the article:

The Trump administration is resuming Obamacare’s risk adjustment program, just weeks after it abruptly froze billions of dollars in insurer payments citing a court ruling invalidating parts of the program. CMS late Tuesday night issued a final rule that it said clarifies the program methodology and addresses issues raised earlier this year by a federal judge, clearing the way for the government to begin making payments again.

“Issuers that had expressed concerns about having to withdraw from markets or becoming insolvent should be assured by our actions today,” CMS Administrator Seema Verma said. The risk adjustment program, created to protect Obamacare insurers that attract sicker and more expensive customers, has been targeted in court by some companies that allege it penalizes smaller startup health plans. The freeze affected 2017 payments totaling $10.4 billion…

…Ways and Means Chairman Kevin Brady praised the move. Not making the payments “would have had a devastating impact and increased health care costs on millions of hardworking Americans,” he said…

July 25, 2018: The U.S. House of Representatives voted on H.R. 6311 “Increasing Access to Lower Premium Plans and Expanding Health Savings Accounts Act of 2018”.  The vote was 242 AYES to 176 NAYS. This means that H.R. 6311 has passed the House of Representatives. It will go to the Senate next.

  • 239 Republicans voted AYE
  • 12 Democrats voted AYE
  • 1 Republican voted NAY
  • 175 Democrats voted NAY
  • 10 Representatives did not vote

Some of the text of H.R. 6311 says:

To amend the Internal Revenue Code of 1986 and the Patient Protection and Affordable Care Act to modify the definition of qualified health plan for the purposes of the health insurance premium tax credit and to allow individuals purchasing health insurance in the individual market to purchase a lower premium copper plan.

Other key parts of H.R. 6311 include:

  • Carryforward of health flexible spending arrangement account balances: A plan shall not fail to be treated as a health flexible spending arrangement under this section or section 105 merely because the lesser of – (1) such arrangement’s account balance (or any portion thereof) determined at the end of any plan year, or (2) the product of the dollar limitation in effect under section 125(i) for such a plan year… multiplied by 3, may be carried forward to the succeeding plan year.
  • Coordination with limitation on salary reduction contributions: Coordination with carry forward of account balances – The dollar amount otherwise in effect under paragraph (1) for any plan year shall be reduced (but not below zero) by the excess (if any) of – (A) the amount of any account balance which is carried forward to such plan year from the preceding year, over (B) twice the dollar limitation in effect under paragraph (1) (determined without regard to this paragraph).
  • Maximum contribution limit to health savings account increased to amount of deductible and out-of-pocket limitation: In short, this part raises the limitation on Self-Only coverage, and on Family coverage.
  • Allows both spouses to make catch-up contributions to the same health savings account
  • Special rule for certain medical expenses incurred before the establishment of health savings account: If a health savings account is established during the 60-day period beginning on the date that coverage of the account beneficiary under a high deductible health plan begins, then, solely for purposes of determining whether an amount paid is used for a qualified medical expense, such account shall be treated as having been established on the date that such coverage begins.
  • Allowance of bronze and catastrophic plans in connection with health savings accounts
  • Allowing all individuals purchasing health insurance in the individual market the option to purchase a lower premium copper plan.
  • Delay of reimposition of annual fee on health insurance providers: This part strikes the date “December 31, 2019” and replaces it with “December 31, 2021”.

July 25, 2018: The U.S. House of Representatives voted on H.R. 6199 “Restoring Access to Medication Act of 2018”. The vote was 277 YEAS to 142 NAYS. This means that H.R. 6199 has passed the House of Representatives. It will go to the U.S. Senate.

  • 231 Republicans voted YEA
  • 46 Democrats voted YEA
  • 1 Republican voted NAY
  • 141 Democrats voted NAY
  • 9 Representatives did not vote

The Summary of H.R. 6199 (as written by the nonpartisan Congressional Research Service) is:

This bill repeals provisions of the Internal Revenue Code, as added by the Patient Protection and Affordable Care Act, that limit payments for medications from health savings accounts, medical savings accounts, health flexible spending arrangements, and health reimbursement arrangements to only prescription drugs or insulin (thus allowing distributions from such accounts for over-the-counter drugs). The bill also allows the accounts to be used for menstrual care products.

July 25, 2018: USA Today posted an article titled: “House votes to delay Obamacare insurance tax, loosen health savings accounts restrictions”. It was written by Ken Alltucker. From the article:

The House of Representatives voted Wednesday on bills to delay an Affordable Care Act tax and allow consumers broader use of health savings accounts.

In a 242-176 vote, House Republicans joined one dozen Democrats to support a bill that would postpone the health insurance tax through 2021. The tax, which already had been delayed through 2019, is intended to help fund the health law’s insurance expansion.

But House Republicans said the tax helped drive the cost of health insurance premiums higher. Democrats blamed the Trump administration’s actions for higher insurance premiums this year and said eliminating the tax would reduce federal revenue by $50 billion over the next decade, worsening the federal deficit.

Another health-related tax bill allowing consumers to use health savings accounts to purchase over-the-counter medications and other health-related products received bipartisan support in a 277-142 vote.

Other provisions would allow consumers to use health savings accounts for exercise and fitness programs and for “direct primary care” doctors who give patients expanded access in exchange for an annual fee. The measure also would allow consumers to carry a balance from year to year in flexible-spending accounts; these accounts now require users to spend the entire account within a calendar year.

The two measures were approved one day after the House voted to repeal a 2.3 percent tax on medical devices, a bill that also received bipartisan support.

Some Democrats said the bills would add to the federal deficit and undermine the Affordable Care Act. They also questioned whether the legislation was intended to help vulnerable lawmakers in an election year…

July 26, 2018: The U.S. Government Accountability Office (GAO) responded to Representative Frank Pallone, Jr, (New Jersey 6th District – Democrat) Ranking Member of the House Committee on Energy and Commerce with a report. From the report:

On July 25, 2017, the U.S. Department of Energy (Energy) issued a tweet concerning a guest column by the Secretary of Energy on health care. The next day, you asked us whether Energy violated any appropriations laws by “us[ing] agency resources on matters well beyond [its] jurisdiction.” We analyzed whether Energy violated the purpose statute, 31 U.S.C.§ 1301, and applicable appropriations law prohibitions on using appropriations for grassroots lobbying or for publicity or propaganda. We find that Energy violated the purpose statute when it tweeted about the Secretary’s Columbia because Energy did not show that its appropriation is available for the purpose of informing the public about health care legislation. As explained below, we also find that Energy did not violate the prohibitions on using appropriations for grassroots lobbying or for publicity or propaganda…

…On July 25, 2017, cleveland.com published the Secretary’s column on health care. In the column, the Secretary criticized “Obamacare,” a common reference to the Patient Protection and Affordable Care Act (PPACA), and advocated for the enactment of “patient-centered reform” that “empower[s] the states.” The Secretary wrote that “[m]illions of Americans are depending on their representatives to repeal this crushing law and can benefit from common-sense solutions being considered in the Senate.” He added that the Better Care Reconciliation Act, then pending in the Senate, included “many positive reforms to Medicaid” and “would give states more control to deliver better care at lower costs for those in need.”…

…Energy’s Office of Public Affairs issued a tweet concerning the column that same day. @EnergyPressSec tweeted: “Time to discard the burdens and costs of Obamacare: @SecretaryPerry” and linked to the Secretary’s column in cleveland.com. E&E News reported that Energy deleted the tweet later in the day. Energy acknowledged that the tweet occurred.

Energy obligates amounts for the expenses of its Office of Public Affairs from its Departmental Administration appropriation….

…The purpose statute, 31 U.S.C. § 1301, provides that appropriations are only available for the purpose for which Congress has provided. In order to interpret the purpose of an appropriation, we turn to its statutory language.

The Departmental Administration appropriation is a lump-sum appropriation that is broadly available for “salaries and expenses of the Department of Energy necessary for departmental administration in carrying out the purposes of the Department of Energy Organization Act… The Department of Energy Organization Act, in turn, authorizes Energy to carry out various energy programs. Because neither the appropriation nor the authorization plainly makes amounts available for the purpose of informing the public about health care, we apply the “necessary expense” rule and first consider whether Energy’s expenditure bears a reasonable and logical relationship to the purpose of this appropriation…. We generally look to the agency to determine whether an expenditure is reasonably related to accomplishing its statutory mission, but the relationship must not be “so attenuated as to take it beyond that range” or permissible discretion…

…Energy told us that it obligates its Departmental Administration appropriation for the Office of Public Affairs, which “facilitate[s] the dissemination of information relevant to the agency and administration.” Energy Letter, at 1 (emphasis added). With regard to whether Energy’s appropriation is available to disseminate information “relevant to the agency,” we agree that an agency’s appropriations are generally available to communicate with the public about agency activities…. In its congressional budget justification for fiscal year (FY) 2017, Energy explains that the mission of its Office of Public Affairs is to “communicate information about DOE’s work in a timely, accurate, and accessible way to the news media and the general public.” Here, however, Energy did not provide any explanation or make any particularized showing that communicating about health care is part of its work or is related to accomplishing its statutory mission…

…Here, however, Energy merely asserted – with no further explanation or support – that its Departmental Administration appropriation was available for disseminating information important to the administration. Energy Letter, at 1. As explained above, in order to use this appropriation, Energy would have to show a reasonable and logical relationship between tweeting about health care and the purposes of its Departmental Administration appropriation. Energy did not make this connection. In other words, Energy did not meet the requirements of the necessary expense rule because it did not show that the tweet was reasonably and logically related to the purpose of its appropriation. Therefore, we find that Energy violated the purpose statute, 31 U.S.C. § 1301…

July 26, 2018: The Hill posted an article titled: “Congressional watchdog finds Energy Dept. violated law with anti-ObamaCare tweet”. The article was written by Peter Sullivan.  From the article:

A congressional watchdog agency found Thursday that the Department of Energy violated the law last year with a negative tweet about ObamaCare.

The report from the Government Accountability Office, an investigative arm of Congress, finds that the Department of Energy violated the law because its funding is not directed to be used for health-care messaging.

The tweet in question, from last July, linked to an anti-ObamaCare opinion piece by Energy Secretary Rick Perry, stating, “Time to discard the burdens and costs of Obamacare: @SecretaryPerry.”

The agency deleted the tweet later in the day.

“We find that Energy violated the purpose statute when it tweeted about the Secretary’s column because Energy did not show that its appropriation is available for the purpose of informing the public about health care legislation,” the GAO report states.

Rep. Frank Pallone Jr. (N.J.), the top Democrat on the House Energy and Commerce Committee, denounced the Trump administration over the findings…

July 26, 2018: The Hill posted an article titled: “Trump says new health plans, not available until September, already doing ‘record business'”. It was written by Brett Samuels. From the article:

President Trump on Thursday touted his administration’s new health insurance plans, which aren’t available to the public until Sept. 1, saying they’re already generating “record business.”

Speaking at a roundtable in Iowa, where he was joined by state and local officials, as well as a few members of his Cabinet, the president highlighted forthcoming health plans that serve as alternatives to the ones offered under ObamaCare.

Trump said Alex Acosta, who was at the event, “has come up with incredible healthcare plans.”

“Alex, I hear it’s like record business that they are doing,” Trump said of the plans, which aren’t available for another five weeks. “We just opened about two months ago and I’m hearing that the numbers are incredible — the numbers of people getting really, really, good healthcare instead of Obamacare, which is a disaster.”…

…Trump did not site any numbers regarding the health plans at Thursday’s event, while Acosta said he’d heard Iowa businesses are “putting those associations together.”

The Labor Department has said associations cannot establish association health plans until Sept. 1…

July 26, 2018: The Fiscal Times posted an article titled: “Top Trump Health Official Slam Obamacare, Medicare for All”. It was written by Yuval Rosenberg. From the article:

In a speech Thursday morning at the conservative Heritage Foundation, Health and Human Services Secretary Alex Azar criticized the Affordable Care Act and said that the Trump administration was committed to “building markets and competition, restoring price signals and incentives, and empowering consumers through choice, rather than having government decide what is best for the individual.”

The Fiscal Times article then lists some of what Azar said.  Here is a one quote:

  • Obamacare’s Medicaid expansion made the program “a free source of coverage for 15 million new able-bodied adults, including many without children. In fact, the ACA offers more generous support for states to insure these populations, currently covering more than 90 percent of their costs, than it does for traditional Medicaid populations. Supporting legislation to undo those perverse incentives is a priority for this administration. But in the meantime, we want to rethink how Medicaid serves able-bodies, working-age adults, which is why we have encouraged states to consider work and community requirements for these populations.”

…Azar’s comments come a day after another top Trump administration health care official, Centers for Medicare and Medicaid Services Administrator Seema Verma, also critiqued the Affordable Care Act. “It wasn’t working when we came into office and it continues not to work,” she said. “The program is not designed to be successful.”

Verma also took a swipe at the idea of “Medicare for all,” which has become increasingly popular with Democrats. Verma said the idea would endanger Medicare’s focus on seniors. “We don’t want to divert the purpose and focus away from our seniors,” she said. “In essence, Medicare for all would become Medicare for none.”

Verma also said she didn’t think a single-payer system would work. “By choosing a socialized system, you are giving the government complete control over the decisions pertaining to your care or whether you receive care at all. It would be the furthest thing from patient-centric care,” she said in her speech…

July 27, 2018: Bloomberg posted an article titled: “States Could Change Obamacare”. It was written by Sara Hansard. From the article:

States may soon get more leeway to make changes to Obamacare that could affect the comprehensiveness of coverage…

…Section 1332 of the Affordable Care Act enables states to ask for permission from the Department of Health and Human Services to make changes to the ACA, including changes to requirements on health plans and the ACA marketplaces, as well as changes to the ACA-mandated essential health benefits coverage and to the financial assistance system.

But there are “guardrails” on those major changes written into the law, requiring that coverage be at least as comprehensive and affordable as it would be without waivers, a comparable number of residents are covered, and the waiver doesn’t increase the federal deficit…

…About 87 percent of people enrolled in marketplace plans receive subsidies, but from 2016 to 2017, the number of people who didn’t receive subsidies dropped 20 percent in the ACA-compliant individual market, according to a recent HHS report.

For example, many people in the individual market in Wisconsin are farmers who used to purchase health insurance policies that included work-related injuries before the ACA rules took effect, Wisconsin Deputy Commissioner of Insurance J.P. Weiske said. Wisconsin would like to add benefits to its individual plans to make them more useful to farmers, he said.

Wisconsin is also looking for more flexibility to promote the use of association health plans, Weiske said. The Trump administration recently issued final rules that make it easier to offer association health plans, which may not comply with all ACA requirements.

July 29, 2018: Forbes posted an article titled: “As Trump Attacks, Insurers Boost Obamacare Marketing”. It was written by Bruce Japsen. From the article:

Large health insurers have joined the parade of startups investing more in marketing and operations to expand their geographic footprints and sell more individual coverage under the Affordable Care Act.

Anthem, the nation’s second-largest health insurer, said last week its performance has improved from last year when losses triggered a major retreat from Obamacare. So much so, Anthem last week said the number of individual customers dropped by more than 1 million to 712,000 in the second quarter compared to last year.

But Anthem executives say the insurer’s ACA individual business has stabilized enough that the operator of Blue Cross and Blue Plans in 14 states will expand in 2019 near areas where it still offers Obamacare coverage. It didn’t specify which states would see expansions, executives said in an update during Anthem’s second quarter earnings call…

…Centene is the largest player in the Obamacare business, ending the second quarter with 1.5 million marketplace health plan members, which is up from 10.8 million last year, the insurer reported least week…

…This year, Centene entered Kansas, Missouri, and Nevada and expanded in six other states where it already sells individual ACA policies, including markets Aetna, Humana, and UnitedHealth Group scaled back or left altogether. In 2019, Centene is filing with states to expand into new states and expand offerings in areas where it already sells ACA-compliant individual coverage…

…Bright Health will enter Arizona and Tennessee with individual plans in 2019 on the ACA’s public exchanges after already selling ACA-compliant policies in Colorado and Alabama this year. And Oscar Health has said it would sell health insurance in six new markets, the insurer said last month…

July 29, 2018: Milwaukee Journal Sentinel posted an article titled: “Scott Walker’s $200 million plan to lower Obamacare costs gets OK from Trump administration”. It was written by Patrick Marley and Samantha Hernandez. From the article:

President Donald Trump’s administration signed off Sunday on Gov. Scott Walker’s $200 million plan to lower Affordable Care Act premiums.

It was the latest effort by the GOP governor to work within the confines of Obamacare as he simultaneously tries to end the federal health care law…

…Under Walker’s plan, consumer costs are expected to go down by 3.5 percent on average next year for individuals getting insurance through the marketplaces established by the act.

Democrats dismissed Walker’s plan as an election-year effort by the governor to score points on health care while refusing to accept additional federal money under Obamacare for the state’s BadgerCare Plus health program…

…Wisconsin taxpayers will spend $34 million on Walker’s plan. The remaining $166 million will come from federal taxpayers…

Walker and lawmakers approved their plan in February but needed permission from the Centers for Medicare and Medicaid Services because the federal government would fund the bulk of it.

They received the federal approval Sunday, and within hours Walker put his signature on it during his stop here. The plan will take effect Jan. 1.

Under the plan, the number of people getting insurance on the Obamacare marketplace would dip in 2019 to an estimated 184,000.

The program – dubbed the Health Care Stability Plan – is targeted at consumers who buy individual health insurance through the Affordable Care Act but who make too much money to qualify for federal subsidies to lower their premiums. Those consumers saw their premiums go up by 44 percent in 2018 in Wisconsin….

Walker’s plan will help insurers cover the cost of patients with claims of $50,000 to $250,000. With the Walker plan covering half those costs, insurers will be able to charge lower premiums.

Under the plan, premiums on average will drop 3.5 percent from current levels and will be 11 percent lower than they would have been in 2019 without the plan, according to his administration. Walker noted that not everyone will see a reduction in their premiums.

Now, individuals using the Obamacare marketplaces in Wisconsin pay a monthly premium of $762.

Walker’s plan won the backing of the Wisconsin Hospital Association, though the group contended the government needs to pay hospitals more to care for people who get health care through BadgerCare and other Medicaid programs…

August 1, 2018: USC-Brookings Schaeffer Initiative for Health Policy posted an analysis titled “How Would Individual Market Premiums Change in 2019 in a Stable Policy Environment?” It was written by Matthew Fiedler.  Here is some key points from the Introduction:

In recent weeks, insurers in many areas of the country have unveiled the premiums they propose to charge for individual market health insurance policies in 2019. In setting premiums for 2019, insurers are taking account of several policy changes that will be newly in effect for the 2019 plan year, including repeal of the individual mandate penalty and Trump Administration actions to expand the availability of plans that are exempt from various Affordable Care Act (ACA) requirements. These policy changes are generally expected to cause many healthier people to leave the individual market and thereby raise individual market premiums…

…This analysis examines how premiums might have changed in 2019 in a stable policy environment. To do so, I first estimate insurers’ revenues and costs in the ACA-compliant individual market through 2018, drawing primarily on insurers’ reports to state and federal regulators. With these estimates as a starting point, I then estimate how premiums would have changed in 2019 under various assumptions about how insurers’ costs and margins would have evolved in 2019 without the major pending policy changes. This analysis reaches two main conclusions:

  • Insurers will earn large profits in the ACA-compliant market in 2018: I project that insurers’ revenues in the ACA-compliant market will far exceed their costs in 2018, generating a positive underwriting margin of 10.5 percent of premium revenue. This is up from a modest positive margin of 1.2 percent of premium revenue in 2017 and contrasts sharply with the substantial losses insurers incurred in the ACA-compliant market in 2014, 2015, and 2016. The estimated 2018 margin also far exceeds insurers’ margins in the pre-ACA individual market. These estimates for 2018 as a whole are broadly consistent with estimates for the first quarter of 2018 derived from insurers’ first quarter financial filings by researchers at the Kaiser Family Foundation…

The estimated improvement in insurers’ margins for 2018 is driven by the substantial premium increases implemented for 2018, which will almost certainly be more than sufficient to offset the loss of cost-sharing reduction (CSR) payments and what appears likely to be another year of moderate growth in underlying claims spending. Prior analysis of insurers’ 2018 rate filings suggest that many insurers expected policy changes that are now scheduled to take effect in 2019, notably repeal of the individual mandate penalty, to take effect in some form during 2018…This may have led insurers to incorporate those policy changes into their premiums a year early.

  • In a stable policy environment, average premiums for ACA-compliant plans would likely fall in 2019: In this analysis, I define a stable policy environment as one in which the federal policies toward the individual market in effect for 2018 remain in effect for 2019. Notably, this scenario assumes that the individual mandate remains in effect for 2019, but also assumes that policies implemented prior to 2018, like the end of CSR payments, remain in effect as well. Under those circumstances, insurers’ costs would rise only moderately in 2019, primarily reflecting normal growth in medical costs. Meanwhile, for reasons I discuss in detail in the main text, it is unlikely that insurers would set 2019 premiums with the goal of keeping margins at their unusually high 2018 level. Downward pressure on premiums from falling margins would likely offset upward pressure on premiums from underlying cost pressures, so premiums would fall on net.

Indeed, under my base assumptions, I estimate that the nationwide average per member per month premium in the individual market would fall by 4.3 percent in 2019 in a stable policy environment. This estimate is subject to some uncertainty, primarily because of uncertainty about underlying individual market claims trends and about the margins insurers are likely to target for 2019. However, I estimate that average premiums would have declined in a stable policy environment under a range of plausible alternative assumptions…

August 2, 2018: Axios posted an article titled: “Trump’s effect on ACA premiums”. It was written by Sam Baker. From the article:

ACA premiums would probably be going down next year if the Trump administration and congressional Republicans had simply left it alone, Brookings’ Matt Fiedler says in a new analysis this morning.

The big picture: Insurers are raking in money this year, largely thanks to the very large premium hikes they enacted. They’ll likely see a profit margin north of 10% on their ACA business this year, up from 1.2% last year and losses in the years before.

Fielder estimated what would happen if the regulatory status quo at the beginning of 2018 had carried over into 2019. In that world, cost-sharing payments would still be gone, but the individual mandate would remain in place and the expansion of short-term plans wouldn’t have happened…

August 2, 2018: The Hill posted an article titled: “Four cities sue Trump saying ObamaCare ‘sabotage’ violates Constitution”. It was written by Peter Sullivan. From the article:

Four cities on Thursday sued President Trump, arguing that he is violating his constitutional duty to enforce the law by ‘sabotaging’ ObamaCare.

The cities of Baltimore, Chicago, Columbus and Cincinnati filed the lawsuit in federal court in Maryland, arguing that Trump’s actions against the Affordable Care Act violate the Constitution’s provision that the president “shall take care that the laws be faithfully executed.”

The lawsuit states that Trump’s actions are “an affront to the rule of law: to our constitutional system, under which Congress enacts laws and the President faithfully implements them.”

The lawsuit points to a range of administration actions in arguing the case, including that it expanded insurance options that do not comply with the health-care laws rules, that it cut funding for outreach to help people sign up for coverage, and that it shortened the sign-up period for ObamaCare…

…It cites Trump’s statements like “we are getting rid of ObamaCare,” and “essentially, we have gotten rid of it” to argue that Trump has sabotaged the law…

A copy of the lawsuit is viewable on DemocracyForward.org.  Here are some key points:

The Plaintiffs in the lawsuit are:

  • City of Columbus
  • Mayor and City Council of Baltimore
  • City of Cincinatti
  • City of Chicago
  • Stephen Vondra – Democracy Forward Foundation
  • Bonnie Morgan – Democracy Forward Foundation

The Defendants in the lawsuit are:

  • Alex M. Azar II, in his official capacity as Secretary of the United States Department of Health and Human Services
  • United States Department of Health and Human Services
  • Seema Verma, in her official capacity as Administrator of the Centers for Medicare and Medicaid Services
  • Centers for Medicare and Medicaid Services

Here are some key parts of the first section of the Complaint:

…1. Having failed to persuade Congress to repeal the Affordable Care Act, President Trump and his Administration are waging a relentless campaign to sabotage and, ultimately, to nullify the law. President Trump has repeatedly admitted as much: because Congress rejected his demand to have “Obamacare repealed,” he has said, he decided “to go a different route” and “end [ ] Obamacare” through his actions. To that end, President Trump and his Administration are deliberately trying to make the Act fail. They are discouraging Americans from enrolling in comprehensive plans that protect them against debilitating medical expenses. They are working to raise prices and reduce choices for Americans seeking insurance in the Act’s exchanges. And they are misappropriating funds Congress allocated to support the Act, instead using those funds to attack it. The Trump Administration’s strategy: to deceptively shift the blame from their own actions to the Act itself. Their objective: to pressure Congress to repeal the Act or, if that fails, to achieve de facto repeal through executive action alone. The Administration’s actions are unlawful.

2. The scope of this Complaint is testament to the breadth and persistence of the Trump Administration’s efforts to undermine the Affordable Care Act (“ACA”). As Plaintiffs – individuals and cities representing almost 4.5 million Americans – allege in detail below, the Administration has tried to prevent families from obtaining health insurance through the ACA’s exchanges by, for example:

  • promoting insurance that does not comply with the ACA’s requirements, including insurance that does not cover preexisting conditions;
  • slashing funding for outreach strategies that have been proven to encourage individuals, and healthy individuals in particular, to sign up for coverage;
  • misusing federal funds for advertising campaigns aimed at smearing the ACA and its exchanges, and spinning false narratives about the efficacy and success of the Act;
  • providing individuals and families with less time to choose a plan that is appropriate for them;
  • imposing unnecessary and onerous documentation requirements, making enrollment even harder

In addition, the Administration has worked to increase premiums for ACA-compliant insurance by, for example, shirking oversight of insurance rate increases and reducing rebates owed to consumers when insurers underperform. Finally, the Administration has attempted to make affordable, high-quality health insurance unavailable by sowing uncertainty in insurance markets, causing insurers to raise rates or exit markets altogether.

3. President Trump and his Administration have been remarkably transparent about their intent and their approach. “If we don’t get it done” in Congress, President Trump has said, “we are going to watch Obamacare go down the tubes, and we’ll blame the Democrats…[a]nd at some point, they are going to come and say, ‘You’ve got to help us.””. “[W]e are getting rid of Obamacare, President Trump boasted, “essentially, we have gotten rid of it,” “[I]t’s dead[,] [i]t’s essentially dead,” “there is no Obamacare, it’s dead.” Of course, as a matter of constitutional law, the Affordable Care Act has not been repealed; as a matter of fact, it is not dead, and indeed has proven more resilient than the Administration might have hoped. But the Administration’s death-by-a-thousand-cuts campaign to undermine the Act via executive action alone has also taken a toll.

4. All Americans are, quite literally, paying the price. The Trump Administration’s actions are driving insurers out of ACA exchanges, raising premiums, and increasing the population of underinsured and uninsured individuals. Defendants’ actins are therefore imposing significant costs on families and governments nationwide, including Plaintiffs in this case. Specifically, the Trump Administration’s actions force the cities of Columbus, Ohio, Baltimore, Maryland, Cincinnati, Ohio, and Chicago, Illinois, to spend more on uncompensated care for their residents. The Trump Administration’s actions force Steve Vondra and Bonnie Morgan to pay more for the quality health insurance coverage they need – insurance that, for example, covers Steve’s preexisting condition. That is the precise opposite of what Congress intended the ACA to achieve. Congress passed the ACA to make comprehensive health insurance more affordable and to reduce the costs of uncompensated care. The ACA was achieving both those aims before the Trump Administration came to power.

5. The Trump Administration’s actions are also an affront to the rule of law; to our constitutional system, under which Congress enacts laws and the President faithfully implements them. The Administration’s actions raise questions that go to the heart of our structure of government: whether the executive branch must “take care that the laws be faithfully executed,”… and whether the Constitution therefore prohibits the President and his appointees from welding executive power to destroy a duly-enacted law. The Administration’s actions violate the Take Care Clause and the Administrative Procedure Act. They should be declared unlawful and set aside….

THIS BLOG POST WILL BE UPDATED WHENEVER RELEVANT NEWS IS RELEASED.

A Timeline of the GOP’s Attempts to Destroy Obamacare is a post written by Jen Thorpe on Book of Jen and is not allowed to be copied to other sites.

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