Let A Senator Know How You Feel About the BCRA

For those interested in pressuring senators to oppose the BCRA, here is a list of “No” and “Undecideds” compiled by Huffington Post.  A link to contact information appears at the bottom of the post.

Here’s a look at where McConnell’s conference stands on the legislation.

The Hill will be updating this list as Republican senators offer statements of support or opposition. Please send updates to mmali@thehill.com.

 

No (6)

Sen. Susan Collins (Maine) — The Maine centrist says she will not back a procedural motion on the bill after seeing the CBO score. “I cannot support a bill that’s going to make such deep cuts in Medicaid that it’s going to shift billions of dollars of costs to our state governments,” she said Sunday on ABC’s “This Week,” a day before the score came out.

Sen. Ted Cruz (Texas) — In a statement Thursday, the conservative former presidential candidate said he opposed the bill. Cruz said the bill did not do enough to lower health costs. He has floated an amendment that would let insurers sell plans that are not compliant with ObamaCare requirements.

Sen. Dean Heller (Nev.) — Heller said Friday he opposed the bill, raising concerns about the phaseout of the Medicaid expansion. “It’s going to be very difficult to get me to a yes,” he said. Heller is viewed as the most vulnerable GOP senator up for reelection next year, so his vote will be closely watched. Heller has indicated he would vote against taking up the bill in a procedural vote without changes.

Sen. Ron Johnson (Wis.) — Johnson on Thursday joined three of his colleagues in opposing the bill. He has expressed worries the bill doesn’t do enough to lower premium costs. On NBC’s “Meet The Press” Sunday, Johnson said “we should not be voting on this next week.” “I don’t have the feedback from constituencies who will not have had enough time to review the Senate bill.” He has also criticized GOP leaders for rushing the legislation and says he may not back a procedural motion unless the bill is changed.

Sen. Mike Lee (Utah) — The conservative joined Paul, Johnson and Cruz in a statement opposing the bill on Thursday. In a Friday blog post on Medium, he noted that conservatives have compromised on “every substantive question in the bill.” But added he hadn’t “closed the door” on voting for some version of it and would support it “if it allowed states and/or individuals to opt-out of the Obamacare system free-and-clear to experiment with different forms of insurance, benefits packages, and care provision options.”

Sen. Rand Paul (Ky.) — Paul is McConnell’s home-state fellow senator, but he may be a hard get. He also says he’ll oppose the procedural motion. “The current bill does not repeal Obamacare. It does not keep our promises to the American people. I will oppose it coming to the floor in its current form, but I remain open to negotiations,” Paul said in a statement Thursday.

Undecided/Unclear (20)

Sen. Bill Cassidy (La.) — Cassidy won headlines when he talked about how the bill needed to pass a “Jimmy Kimmel test” on whether it would prevent children with pre-existing conditions from getting coverage. Cassidy told CBS’s “Face the Nation” Sunday he needed more time to consider the bill. “Right now, I am undecided. There are things in this bill that adversely affect my state, that are peculiar to my state, but if those can be addressed, I will. If they can’t, I won’t,” Cassidy said about his vote.

Sen. Shelley Moore Capito (W.Va.) — Capito has been involved in talks about the phaseout of ObamaCare’s federal funding expanding Medicaid. She’s also worried about how Medicaid cuts could effect the opioid epidemic. Like other senators, she said she would be reviewing the draft. She did not mention any concerns, but said she wanted to access to affordable healthcare for those on Medicaid and those struggling with drug addiction.Sen. Bob Corker (Tenn.) — Asked if he would support the bill, Corker told reporters it would “irresponsible” for lawmakers to take a position already, adding that “this draft we’re looking at is not necessarily the draft that’s going to be entered into the record” and could undergo “significant amendments.”

Sen. Steve Daines (Mont.) — “I look forward to hearing directly from Montanans on this legislation,” Daines said in a statement Thursday.

Sen. Joni Ernst (Iowa) — Ernst, who has not yet taken a position on Senate Republicans’ ObamaCare repeal and replace plan, is polling her constituents to gauge their feelings on the bill.

Sen. Jeff Flake (Ariz.) — Flake, who is up for reelection in 2018, tweeted “just got my copy of the #healthcare bill and I’m going to take time to thoroughly read and review it.”

Sen. Cory Gardner (Colo.) — Gardner on Thursday said he was “carefully reviewing” the bill and called for more time. “If we can have opportunities to make the bill better, then by all means let’s take every chance and (all the) time we can,” he said, according to the Denver Post.

Sen. John Hoeven (N.D.)  — Hoeven said in a statement that he “will review this legislation to determine whether it meets this standard and we also want to see a CBO score on the bill.”

Sen. Johnny Isakson (Ga.) — Isakson said in a statement that “I am fully and thoroughly reviewing the draft of the Republican health care plan that was released today. The stark reality remains that if we do nothing, Obamacare will fail, and Americans will suffer.”

Sen. James Lankford (Okla.) — Lankford told CNN that he has found six areas where he has “problems and suggestions,” adding “none of them are showstoppers … but there are problems we need to fix before we get this into law.”

Sen. John McCain (Ariz.) — “I think it’s a good proposal overall. I’m going to have to look at it,” McCain told reporters Thursday.

Sen. Jerry Moran (Kan.) — Moran said in a statement that he is “awaiting the Congressional Budget Office score to gain a complete understanding of the impacts and consequences this bill would have on hardworking Kansans.”

Sen. Lisa Murkowski (Alaska) — Along with Collins, Murkowski has suggested she might not back a bill that defunds Planned Parenthood. The Senate bill would block funding for a year.

Sen. David Perdue (Ga.) — “I’m looking at this thing. I’m not ready to say yes or no on it because I want to read this in detail,” he said.

Sen. Rob Portman (Ohio) — “There are some promising changes to reduce premiums in the individual insurance market, but I continue to have real concerns about the Medicaid policies in this bill, especially those that impact drug treatment at a time when Ohio is facing an opioid epidemic,” he said in a statement Thursday. The opioid crisis is a huge problem in Ohio, and Portman has worked with Capito to seek support through the GOP bill on this issue.

Sen. Marco Rubio (Fla.) — Rubio’s office said in a statement that “Senator Rubio will decide how to vote on health care on the basis of how it impacts Florida. He has already spoken to Governor Scott, Senate President Negron and Speaker Corcoran about the first draft of this proposal.”

Sen. Ben Sasse (Neb.) — On Sunday at a Koch summit, Sasse said he is not committed to the GOP’s ObamaCare repeal bill. Sasse told conservative donors the bill was “largely a Medicaid reform package,” according to Vox. “This is not a full repeal or full replace piece of legislation, and that’s dictated by a whole bunch of circumstances. So we are having a conversation about something that’s much smaller than that.”

Sen. Dan Sullivan (Alaska) — In a statement Thursday, Sullivan said he “will read every word” of the bill, looking closely at stabilizing the state’s insurance market, cutting costs and “providing a sustainable and equitable path forward for Medicaid.”

Sen. Thom Tillis (N.C.) — Tillis said the Senate’s bill needs to be a “net improvement” over ObamaCare and “I look forward to carefully reviewing the draft legislation over the next several days.”

Sen. Todd Young (Ind.) — Young on Friday told a group in his home state of Indiana that he is in the undecided column, though he also repeated an earlier statement that “doing nothing is not an option.”

Contact information:  http://www.dailykos.com/stories/2017/6/12/1671161/-Republican-senators-say-their-phones-aren-t-ringing-to-save-the-ACA-so-here-s-the-contact-list?detail=emaildkre

Posted in AHCA, American Health Care Act, Better Care Reconciliation Act, Health Care, Trump, trumpcare | Leave a comment

I Would Short Tourism to the USA

I can personally confirm the unpopularity of DT and the USA in Switzerland where I am currently!

Apparently the sentiment is wide spread: http://www.reuters.com/article/us-usa-trump-image-survey-idUSKBN19I00F?utm_source=applenews

Image of the United States has plunged under Trump, survey shows

By Noah Barkin | BERLIN

 

The image of the United States has deteriorated sharply across the globe under President Donald Trump and an overwhelming majority of people in other countries have no confidence in his ability to lead, a survey from the Pew Research Center showed.

Five months into Trump’s presidency, the survey spanning 37 nations showed U.S. favorability ratings in the rest of the world slumping to 49 percent from 64 percent at the end of Barack Obama’s eight years in the White House.

But the falls were far steeper in some of America’s closest allies, including U.S. neighbors Mexico and Canada, and European partners like Germany and Spain.

Trump took office in January pledging to put “America First”. Since then he has pressed ahead with plans to build a wall along the U.S. border with Mexico, announced he will pull out of the Paris climate accord, and accused countries including Canada, Germany and China of unfair trade practices.

On his first foreign trip as president in early June, Trump received warm welcomes in Saudi Arabia and Israel, but a cool reception from European partners, with whom he clashed over NATO spending, climate and trade.

Just 30 percent of Mexicans now say they have a favorable view of the United States, down from 66 percent at the end of the Obama era. In Canada and Germany, favorability ratings slid by 22 points, to 43 percent and 35 percent, respectively

In many European countries, the ratings were comparable to those seen at the end of the presidency of George W. Bush, whose 2003 invasion of Iraq was deeply unpopular.

“The drop in favorability ratings for the United States is widespread,” the Pew report said. “The share of the public with a positive view of the U.S. has plummeted in a diverse set of countries from Latin America, North America, Europe, Asia and Africa”.

BELOW PUTIN AND XI

The survey, based on the responses of 40,447 people and conducted between Feb. 16 and May 8 this year, showed even deeper mistrust of Trump himself, with only 22 percent of those surveyed saying they had confidence he would do the right thing in world affairs, compared to 64 percent who trusted Obama.

Image of the United States plummets under Trump

The image of the United States in the world has been seriously damaged by President Donald Trump and an overwhelming majority of people in other countries have no confidence in his ability to manage world affairs, a Pew Research Center survey showed.

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The countries with the lowest confidence in Trump were Mexico, at 5 percent and Spain at 7 percent. The only two countries where ratings improved compared to Obama were Russia, where confidence in the U.S. president surged to 53 percent from 11 percent, and Israel, where it rose 7 points to 56 percent.

Globally, 75 percent of respondents described Trump as “arrogant”, 65 percent as “intolerant” and 62 percent as “dangerous”. A majority of 55 percent also described him as a “strong leader”.

The survey showed widespread disapproval of Trump’s signature policy proposals, with 76 percent unhappy with his plan to build the wall on the border with Mexico, 72 percent against his withdrawal from major trade agreements and 62 percent opposed to his plans to restrict travel to the U.S. from some majority-Muslim countries.

On the positive side, the survey showed that 58 percent of respondents had a positive view of Americans in general. And in many regions of the world, a majority or plurality of respondents said they expected relations with the United States to stay roughly the same in spite of Trump.

 

Posted in foreign policy, Trump, Uncategorized | Tagged , , , | Leave a comment

The Senate Health Reform Bill Slashes Medicaid Severely

Posted by AARP

The Better Care Reconciliation Act (BCRA) now under consideration in the Senate would drastically alter the Medicaid program. The proposed Senate bill would change the way the federal government currently funds Medicaid by limiting federal funding and shifting cost over time to both states and Medicaid enrollees. BCRA would subject older adults, adults with disabilities, expansion adults, and non-disabled children under age 19 to mandatory per enrollee caps beginning in 2020. State Medicaid programs would have the option to choose between block grants and per enrollee caps for non-elderly non-disabled non-expansion adults.

The Senate bill would start out using the medical care component of the Consumer Price Index (M-CPI)—a measure of the average out-of-pocket cost of medical care services used by an average consumer—as the growth rate for per enrollee caps.  However, beginning in 2025, it would slash the growth rate to the Consumer Price Index for all urban consumers (CPI-U)—a measure of general inflation that examines out-of-pocket household spending on goods and services used for everyday living. CPI-U does not tie closely to medical costs and will not reflect population growth or the impact of aging. To be clear, none of the proposed growth factors—M-CPI, M-CPI+1, and CPI-U— keep pace with the growth in Medicaid spending.

Although studies have examined the impact of Medicaid spending cuts in the House-passed healthcare bill over a 10 year period (e.g. [CBO] [CMS] [Urban Institute]) we know of none that examine the impacts over a longer time horizon. To fill this gap, the AARP Public Policy Institute has developed a model that looks out an additional decade to capture impacts on Medicaid spending between 2027 and 2036.

By dramatically reducing the per capita cap growth factor beginning in 2025, we project that the Senate bill would cut between $2.0 and $3.8 trillion from total (federal and state) Medicaid spending over the 20-year period between 2017 and 2036 for the four non-expansion Medicaid enrollment groups: older adults, adults with disabilities, children, and non-expansion adults (children with disabilities are excluded because BCRA does not subject them to capped funding). A cut of this magnitude threatens the viability of the program in unprecedented ways and will increase the number of people who no longer have access to essential healthcare services and critical supports.  The projections do not include the proposed cuts to the adult expansion population, which would also be considerable.

Previous analysis by the AARP Public Policy Institute discusses why capping Medicaid is flawed and would leave states and the poorest and sickest Americans holding the bag for the shortfalls that will most certainly occur.

Table 1 shows the cumulative 20-year cuts to Medicaid by eligibility group under the Senate health reform bill for three growth rate projections.  The bill would cap per enrollee cost growth using two measures of inflation (M-CPI and CPI-U), which are highly variable and uncertain, though well short of what is needed to maintain the integrity of the Medicaid program.  It is difficult to plan for such uncertain growth rates, and reasonable projections are far apart.

We present the high, middle, and low case for M-CPI/CPI-U growth rates based on the following:

  • Low Case. Based on historical growth rates. Over the last five years (2012-2016), the M-CPI growth rate has averaged 3.0% per year, and the CPI-U growth rate has averaged 1.32% per year.
  • Middle Case. Based on projections from the Congressional Budget Office. CBO projects M-CPI to grow by 3.7% per year, and CPI-U by 2.4% per year.
  • High Case. Based on projections from 2016 CMS Medicaid Actuarial Report.  From 2019 onward, this report projects M-CPI to grow by 4.2% per year, and CPI-U by 2.6% per year.

 

In short, the lower the cap growth rate, the more severe the Medicaid cuts will be.

 

The charts below demonstrate that for any projection of the bill’s cap growth rates, BCRA will lead to significant funding shortfalls for older adults, adults with disabilities, and non-disabled low-income children and adults. The end result is that states and beneficiaries will be left with severe funding shortages, and states will be forced to cut eligibility, provider rates, or covered services—or very likely all three.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Susan Reinhard is a senior vice president at AARP, directing its Public Policy Institute, the focal point for AARP’s public policy research and analysis. She also serves as the chief strategist for the Center to Champion Nursing in America, a resource center to ensure the nation has the nurses it needs.

 

 

 

 

Jean Accius is vice president of livable communities and long-term services and supports for the AARP Public Policy Institute. He works on Medicaid and long-term care issues.

 

 

 

 

Lynda Flowers is a Senior Strategic Policy Adviser with the AARP Public Policy Institute, specializing in Medicaid issues, health disparities and public health.

 

 

 

Ari Houser is a Senior Methods Adviser at AARP Public Policy Institute. His work focuses on demographics, disability, family caregiving, and long-term services and supports (LTSS).

 

 

 

Posted in AHCA, American Health Care Act, Better Care Reconciliation Act, Health Care, Medicaid, Trump, trumpcare | Tagged , , , | 1 Comment

Are you 64 and making $56,800 a year? Welcome to a $20,500 Trumpcare insurance premium

Posted on Daily Kos
SAN FRANCISCO, CA - JUNE 21:  Healthcare activists hold headstones as they stage a die-in while protesting the Trumpcare bill on June 21, 2017 in San Francisco, California. Dozens of healthcare activists and senior citizens staged a protest outside the San Francisco Federal Building to express their opposition of the American Heathcare Act bill that is being drafted behind closed doors by Republican senators.  (Photo by Justin Sullivan/Getty Images)

Popular vote loser Donald Trump freely admits he called the House version of Trumpcare “mean, mean, mean” and also claimed that he wanted a Senate bill that is “generous, kind, with heart.”  That’s not what he got with the Senate version of Trumpcare, the “Better Care Act.”  In fact, the Congressional Budget Office says it’s just as mean by the numbers, if not more so.

According to their estimates, 15 million people will lose their insurance next year, 2018. An election year.  By 2026, 22 million people who are now insured will have lost that insurance.  Compared to the Affordable Care Act, “an estimated 49 million people would be uninsured, compared with 28 million who would lack insurance that year under current law.”  The biggest hit, as in the House bill, lands on Medicaid.

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 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 in revenues from repealing penalties on employers who do not offer insurance and on people who do not purchase insurance. […]In later years, other changes in 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.

Keep in mind that “later years” part.  This estimate doesn’t go beyond 2026; however the CBO doesn’t think that the so-called “flexibility” for Medicaid that block granting would be for states is all that.  Instead, it would be a burden.  “With less federal reimbursement for Medicaid, states would need to decide whether to commit more of their own resources to finance the program at current-law levels or to reduce spending by cutting payments to health care providers and health plans, eliminating optional services, restricting eligibility for enrollment through work requirements and other changes, or (to the extent feasible) arriving at more efficient methods for delivering services.”  It also projects that post-2026, Medicaid enrollments would continue to fall.

People with individual plans will see “substantial increases in out-of-pocket spending, even though benchmark premiums would decline, on average, in 2020 and later years.” That’s because insurance would pay for a smaller share of benefits. That’s going to be true for “close to half the population, CBO and JCT expect—living in states modifying the EHBs [essential health benefits] using waivers.  People who used services or benefits no longer included in the EHBs would experience substantial increases in supplemental premiums or out-of-pocket spending on health care, or would choose to forgo the services.”

In some areas of the country—particularly sparsely populated ones (are you listening Lisa Murkowski)—the CBO foresees a market collapse, the classic death spiral.  “Some sparsely populated areas might have no nongroup insurance offered because the reductions in subsidies would lead fewer people to decide to purchase insurance—and markets with few purchasers are less profitable for insurers.”

Yes, this bill is mean, mean, mean. But hey, it’s got lots of tax cuts for the very rich, so expect most Republicans to overlook the other parts.

Posted in AHCA, American Health Care Act, Better Care Reconciliation Act, Health Care, Medicaid, Trump, trumpcare | Tagged , , , , , | 2 Comments

Rural hospital association representative: ‘This bill will close hospitals. … People will die’

Posted on Daily Kos
US President Donald Trump shakes hands with Senate Majority Leader Mitch McConnell as he meets with Republican congressional leaders in the Roosevelt Room at the White House in Washington, DC, on June 6, 2017. / AFP PHOTO / NICHOLAS KAMM        (Photo credit should read NICHOLAS KAMM/AFP/Getty Images)

Trump and McConnell agree to make Americans die faster.

Every healthcare association, provider group, and patient advocacy group in the country is on red alert over Trumpcare, Senate Majority Leader Mitch McConnell’s effort to end healthcare in the U.S. as we know it.

“There has never been a rollback of basic services to Americans like this ever in U.S. history,” said Bruce Siegel, president of America’s Essential Hospitals, a coalition of about 300 hospitals that treat a large share of low-income patients. “Let’s not mince words. This bill will close hospitals. It will hammer rural hospitals, it will close nursing homes. It will lead to disabled children not getting services. . . . People will die.”

That National Association of Medicaid Directors—the people who administer the program in every state—agree, but in less blunt language:

Changes in the federal responsibility for financing the program must be accompanied by clearly articulated statutory changes to Medicaid to enable states to operate effectively under a cap. The Senate bill does not accomplish that. It would be a transfer of risk, responsibility, and cost to the states of historic proportions.While NAMD does not have consensus on the mandatory conversion of Medicaid financing to a per capita cap or block grant, the per capita cap growth rates for Medicaid in the Senate bill are insufficient and unworkable.

“Historic” cuts, “insufficient and unworkable” cuts—that’s a bureaucratic way of hitting the panic button. They have every reason to panic—they’re the ones who along with their states’ governors are going to have to make the decisions over who lives with Medicaid and who dies without it. All the while Republicans were screaming about death panels in Obamacare, they were actually plotting out the most cruel way to create them.

Posted in AHCA, American Health Care Act, Better Care Reconciliation Act, Health Care, Medicaid, Trump, trumpcare | Leave a comment

CONGRESS: KEEP AMERICANS COVERED

From The American Association of Medical Colleges

aamc-news-keep-coverage-article-header.jpg

When Congress began considering health care reform, including reforms to Medicaid, the AAMC outlined three key principles we hoped to see included in a reform bill, which we continue to stand behind:

  1. It should maintain or improve current levels of health care coverage.
  2. It should happen as part of a deliberate and thoughtful implementation process.
  3. It should strengthen Medicaid, not weaken it.

Unfortunately, the Senate bill doesn’t include any of these principles. Rather than stabilizing the health care marketplace, this legislation will upend it by crippling the Medicaid program while also placing untenable strain on states and providers.

The Issue

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We are extremely disappointed by the Senate bill. Despite promises to the contrary, it will leave millions of people without health coverage, and others with only bare bones plans that will be insufficient to properly address their needs. As the nation’s medical schools and teaching hospitals see every day, people without sufficient coverage often delay getting the care they need. This can turn a manageable condition into a life-threatening and expensive emergency.

AAMC-member teaching hospitals represent only 5% of hospitals nationally, but we see a much larger percentage of patients on Medicaid and who don’t have insurance. We provide 24% of all Medicaid hospitalizations and 33% of all hospital charity care.
We know what so many people losing coverage will look like:
  • Patients will delay or forego necessary care, leading to more complex conditions, higher costs and overwhelmed emergency departments
  • Costs will increase for all patients due to an increased number of uninsured
  • Without corresponding support for the health care safety net, more uninsured individuals would cause a ripple effect on regional health care networks due to a lack of corresponding support
  • Teaching hospitals will be forced to limit investments in job creation, critical services, and training the next generation of all health professionals

The AAMC is not against health care reform, but, as medical professionals, we are against health care reform that leads to fewer people having coverage—and lower-quality coverage for people who are insured.

 

Posted in AHCA, American Health Care Act, Better Care Reconciliation Act, Health Care, Medicaid, Trump, trumpcare | Leave a comment

Summary of CBO Report on Better Care Reconciliation Act of 2017 (Senate Bill)

June 26, 2017
Cost Estimate
CBO and JCT estimate that enacting the Better Care Reconciliation Act of 2017 would reduce federal deficits by $321 billion over the coming decade and increase the number of people who are uninsured by 22 million in 2026 relative to current law.

Summary

An Amendment in the Nature of a Substitute [LYN17343] as Posted on the Website of the Senate Committee on the Budget on June 26, 2017

The Congressional Budget Office and the staff of the Joint Committee on Taxation (JCT) have completed an estimate of 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.

Following the overview, this document provides details about the major provisions of this legislation, the estimated costs to the federal government, the basis for the estimate, and other related information, including a comparison with CBO’s estimate for the House-passed act.

Effects on the Federal Budget

CBO and JCT estimate that, over the 2017-2026 period, enacting this legislation would reduce direct spending by $1,022 billion and reduce revenues by $701 billion, for a net reduction of $321 billion in the deficit over that period (see Table 1, at the end of this document):

  • 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 CBO projects under current law—and from changes to the Affordable Care Act’s (ACA’s) subsidies for nongroup health insurance (see Figure 1). 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 in revenues 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.

Pay-as-you-go procedures apply because enacting this legislation would affect direct spending and revenues. CBO and JCT estimate that enactment would not increase net direct spending or on-budget deficits in any of the four consecutive 10-year periods beginning in 2027. The agencies expect that savings, particularly from Medicaid, would continue to grow, while the costs would be smaller because a rescinded tax on employees’ health insurance premiums and health plan benefits would be reinstated in 2026. CBO has not completed an estimate of the potential impact of this legislation on discretionary spending, which would be subject to future appropriation action.

Effects on Health Insurance Coverage

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 in 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.

Stability of the Health Insurance Market

Decisions about offering and purchasing health insurance depend on the stability of the health insurance market—that is, on the proportion of people living in areas with participating insurers and on the likelihood of premiums’ not rising in an unsustainable spiral. The market for insurance purchased individually with premiums not based on one’s health status would be unstable if, for example, the people who wanted to buy coverage at any offered price would have average health care expenditures so high that offering the insurance would be unprofitable.

Under Current Law. Although premiums have been rising under current law, most subsidized enrollees purchasing health insurance coverage in the nongroup market are largely insulated from increases in premiums because their out-of-pocket payments for premiums are based on a percentage of their income; the government pays the difference between that percentage and the premiums for a reference plan (which is the second-lowest-cost plan in their area providing specified benefits). The subsidies to purchase coverage, combined with the effects of the individual mandate, which requires most individuals to obtain insurance or pay a penalty, are anticipated to cause sufficient demand for insurance by enough people, including people with low health care expenditures, for the market to be stable in most areas.

Nevertheless, a small number of people live in areas of the country that have limited participation by insurers in the nongroup market under current law. Several factors may lead insurers to withdraw from the market—including lack of profitability and substantial uncertainty about enforcement of the individual mandate and about future payments of the cost-sharing subsidies to reduce out-of-pocket payments for people who enroll in nongroup coverage through the marketplaces established by the ACA.

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 some 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 low 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 health 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 waivers 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 [EHBs], which set the minimum standards for the benefits that insurance in the nongroup and small-group markets must cover; and other related provisions of 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 in 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 in 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 sparsely populated areas might have no nongroup insurance offered because the reductions in subsidies would lead fewer people to decide to purchase insurance—and markets with few purchasers are less profitable for insurers. Insurance covering certain services would become more expensive—in some cases, extremely expensive—in some areas because the scope of the EHBs 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.

Effects on Premiums and Out-of-Pocket Payments

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 benchmark plans 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 smaller share of benefits paid for by the benchmark plans and federal funds provided to directly reduce premiums.

That share of services covered by insurance would be smaller because the benchmark plan under this legislation would have an actuarial value of 58 percent beginning in 2020. That value is slightly below the actuarial value of 60 percent for “bronze” plans currently offered in the marketplaces. Because of the ACA’s limits on out-of-pocket spending and prohibitions on annual and lifetime limits on payments for services within the EHBs, all plans must pay for most of the cost of high-cost services. To design a plan with an actuarial value of 60 percent or less and pay for those high-cost services, insurers must set high deductibles—that is, the amounts that people pay out of pocket for most types of health care services before insurance makes any contribution. Under current law for a single policyholder in 2017, the average deductible (for medical and drug expenses combined) is about $6,000 for a bronze plan and $3,600 for a silver plan. CBO and JCT expect that the benchmark plans under this legislation would have high deductibles similar to those for the bronze plans offered under current law. Premiums for a plan with an actuarial value of 58 percent are lower than they are for a plan with an actuarial value of 70 percent (the value for the reference plan under current law) largely because the insurance pays for a smaller average share of health care costs.

Although the average benchmark premium directly affects the amount of premium tax credits and is a key element in CBO’s analysis of the budgetary effects of the bill, it does not represent the effect of this legislation on the average premiums for all plans purchased. The differences in the actuarial value of plans purchased under this legislation and under current law would be greater starting in 2020—when, for example, under this bill, some people would pay more than the benchmark premium to purchase a silver plan, whereas, under current law, others would pay less than the benchmark premium to purchase a bronze plan.

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.

By 2026, average premiums for benchmark plans for single individuals in most of the country under this legislation would be about 20 percent lower than under current law, CBO and JCT estimate—a smaller decrease than in 2020 largely because federal funding to reduce premiums would have lessened. The estimates for both of those years encompass effects in different areas of the country that would be substantially higher and substantially lower than the average effect nationally, in part because of the effects of state waivers. Some small fraction of the population is not included in those estimates. CBO and JCT expect that those people would be in states using waivers in such a way that no benchmark plan would be defined. Hence, a comparison of benchmark premiums is not possible in such areas.

Some people enrolled in nongroup insurance would experience substantial increases in what they would spend on health care even though benchmark premiums would decline, on average, in 2020 and later years. Because nongroup insurance would pay for a smaller average share 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 states modifying the EHBs using waivers. People who used services or benefits no longer included in the 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 insurance coverage altogether, some enrollees could see large increases in out-of-pocket spending because annual or lifetime limits would be allowed.

Uncertainty Surrounding the Estimates

CBO and JCT have endeavored to develop budgetary estimates that are in the middle of the distribution of potential outcomes. Such estimates are inherently inexact because the ways in which federal agencies, states, insurers, employers, individuals, doctors, hospitals, and other affected parties would respond to the changes made by this legislation are all difficult to predict. In particular, predicting the overall effects of the myriad ways that states could implement waivers is especially difficult.

CBO and JCT’s projections under current law itself are also uncertain. For example, enrollment in the marketplaces under current law will probably be lower than was projected under the March 2016 baseline used in this analysis, which would tend to decrease the budgetary savings from this legislation. However, the average subsidy per enrollee under current law will probably be higher than was projected in March 2016, which would tend to increase the budgetary savings from this legislation. (For a related discussion, see the section on “Use of the March 2016 Baseline” on page 15.)

Despite the uncertainty, the direction of certain effects of this legislation is clear. For example, the amount of federal revenues collected and the amount of spending on Medicaid would almost surely both be lower than under current law. And the number of uninsured people under this legislation would almost surely be greater than under current law.

Intergovernmental and Private-Sector Mandates

CBO has reviewed the nontax provisions of the legislation and determined that they would impose intergovernmental mandates as defined in the Unfunded Mandates Reform Act (UMRA) by preempting state laws. Although the preemptions would limit the application of state laws, they would impose no duty on states that would result in additional spending or a loss of revenues. JCT has determined that the tax provisions of the legislation contain no intergovernmental mandates.

JCT and CBO have determined that the legislation would impose private-sector mandates as defined in UMRA. On the basis of information from JCT, CBO estimates that the aggregate cost of the mandates would exceed the annual threshold established in UMRA for private-sector mandates ($156 million in 2017, adjusted annually for inflation).

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