**Please note that this is my personal commentary, and I am not speaking for any person or entity but myself.
On Monday, House republicans released their long-awaited answer on a replacement to the 2010 Affordable Care Act in the form of two ACA repeal bills (one in Commerce and one in Ways and Means). While Obama's ACA didn't accomplish much in terms of health system reform, its success can be measured in terms of real strides in parity, access, and cost-savings for poorer folks.
I wish I could say anything other than this replacement plan strips many of these strides away. But, I can't. This replacement plan strips many of these strides away.
Since I am a positive and optimistic creature, I'll start with the good stuff. Young adults can stay on their parents insurance until age 26. Payments are increased to FQHCs (Federally Qualified Health Centers that primarily serve vulnerable rural populations). Ummm. States don't have to do much until 2019/2020? Medicaid as a program isn't going away? I'm having trouble here.
OK, we'll get to the bad stuff now. And, I do have to say, when I was a graduate student I was much more even-handed in my blog posts and tried not to let my political views color the topic. Now, I really couldn't give a shit. Here we go.
General provisions:
The public health fund, money provided for necessary preventive care to the CDC to distribute to state health agencies? Gone.
Money given through Medicaid and managed care organizations to "prohibited entities" which include non profit essential health centers and family planning centers that provide abortions? Frozen for one year. *This one is really murky and unclear. A lot of media is touting this as the "Defunding of Planned Parenthood" but it's really not that simple. Federal money has never paid for abortions except in certain situations, and the actual bill language doesn't change this. Much of Washington's family planning medicaid services are provided through a 1915b Waiver, which would also be protected. We need to wait and see on this one, but it may be good to vocalize that this part of the bill should be struck due to lack of clarity alone.
Medicaid "Modernization" (ugh)
This is where it gets really crappy. I'll do my best to summarize what this would mean for our state and the rest of the nation:
The biggest thing here is that we are moving from a federal match program to a per-capita cap program. that means states don't get half of what they spend from the Fed. They get a set amount for each enrollee per year, based on 2016 spending. If we have an outbreak and people need more care, too bad. We also get penalized if our spending goes over a certain amount for the year. This will have a profound impact on states and will result in serious cuts to who gets to enroll and/or what Medicaid actually covers.
Medicaid will be harder to qualify for: No more presumptive eligibility (you need proof of stuff when you apply, instead of having a grace period), eligibility checks happen every 6 months instead of every 12, and income limits will be lowered for children. No commentary here. Just ugh.
Also, they really care about counting lottery winnings as multiple months worth of income for some reason. Go figure this gets its own section. Again, this will reduce the number of low-income folks who are eligible.
Medicaid will lose parity: The ACA required Medicaid plans to include the 10 essential health benefits also required for private plans. This whole section will be repealed, making it up to states what is covered. WA will likely be fine here, but I worry about other states.
Medicaid expansion will be dis-incentivized, meaning coverage for childless adults will eventually diminish, and/or have less federal funding. This part is really unclear in the bill so I can't comment further on it.
Retroactive coverage will go away. Meaning, if you have a heart-attack and get rushed to the hospital but you qualify for Medicaid, you can sign up later and have your hospital bill covered. No longer, unless your care was in the same month you got coverage.
Insurance Marketplace reforms:
This is where it just gets confusing. They are repealing the individual mandate (the part of the law that says you have to get insurance or pay a penalty), but saying if you try to get coverage after not being covered for 63 days or more, you get a 30% surcharge on your monthly premium. For a year! This is basically a politically savvy way of re-packaging the individual mandate.
We need the individual mandate because we need healthy people to self-select to buy insurance. If we don't, then only sick people buy insurance, and insurance companies have to pay for a lot more care with less premium money coming in from healthy people who aren't using their benefits. Even though the republicans hate the individual mandate, the insurance industry needs it or they will collapse. Think bank-bailout situation in 2008. If our health reform relies on the insurance industry, which in this case it does, they can't repeal the individual mandate without doing something like this.
There's this thing about a patient and state stability fund, presumably to prevent market collapse. I don't think anyone really gets how this would actually work. They are also removing reductions in cost-sharing for low and medium income people, and taking away a whole bunch of taxes. Though, tax credits for individuals will stay.
The insurance marketplace portion of this bill is a mess. They want to repeal the politically unpopular parts of the ACA, but keep the insurance industry from collapsing and premium costs from skyrocketing. They also want to provide hefty tax cuts and reduce penalties to employers. In order to do all of this, they are both taking away provisions that stabilize the market while also adding in new ones, but it all appears to be a hodge-podge of what they think will float politically.
To conclude, these bills hack at all three domains that were addressed by the ACA: Access, parity, and cost-savings. Markup (where they go through and revise the bill) should provide some needed revisions, so we will need to wait and see how these do on the floor. I wish I could end on a hopeful note, but I don't have anything other than this: We Washingtonians are lucky. Our state government is dedicated to access and parity, as well as cost-containment and innovation. I should know, these are the projects I work on. But, there are big changes coming. Be vigilant. Health care is complex, necessary, and important. More to come.
Love,
Bonnie
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