The Administration continues to urge the Senate to return to efforts to repeal and replace the Affordable Care Act (ACA). Senators Bill Cassidy (R-LA) and Lindsey Graham (R-SC) are promoting a bill they cosponsored which includes a Medicaid per capita cap and block grant of the Medicaid expansion funding and the market place subsidies. While their proposal may be revised, The Arc is especially concerned about the proposed cut and caps to Medicaid. Based on a recent opinion by the Senate Parliamentarian, the Senate can return to debate on health care any time before the special budget reconciliation rules for fiscal year 2017 expire on September 30; maintaining the protection of needing only a simple majority to pass the legislation until that date.
The Senate is involved in a number of efforts to address health care issues in a bipartisan manner. The Senate Health Education Labor and Pensions (HELP) Committee, under the leadership of Chairman Lamar Alexander (R-TN) began holding four hearings last week and will continue this week on ideas to stabilize the individual insurance marketplaces. His intent is to reach bi-partisan agreement on a narrow time limited proposal that could be passed by the end of the month. While legislation has not been drafted, the Committee is considering ensuring that funding is appropriated for cost sharing reduction payments that help low income people afford insurance and changes to the existing waiver program that allows states to create marketplaces that do not meet the requirements of the ACA.
The Senate Finance Committee held a hearing on the Children’s Health Insurance Program (CHIP) for which federal funding will expire this year. CHIP was created in 1997 and has strong bi-partisan support. States can create a separate program for children, expand Medicaid, or some combination of both. CHIP has been very successful at expanding insurance coverage for children. The Arc urges Congress to renew funding for CHIP as soon as possible so that states can continue their programs without interruption.
This issue of Capitol Insider is devoted to a review of the Senate’s consideration of the effort to repeal/replace the Affordable Care Act.
Health Care; Medicaid; Long Term Supports and Services –
Repeal of The Affordable Care Act Fails in The Senate: A Week In Review
Last week was a critically important week for people with intellectual and developmental disabilities (I/DD) and their families, indeed, for all people with disabilities. The result was what The Arc and its members had worked hard for over the last nine months. However, the week of Senate legislative action played out like an intense roller-coaster ride and the results were not predictable until the final vote in the early hours of Friday, July 28.
As the week began, Senate Majority Leader Mitch McConnell (R-KY) planned a series of Senate floor votes on the efforts to repeal or replace the Affordable Care Act (ACA) and make fundamental structural changes to the Medicaid program. It was expected that the votes could be close, with 52 Republicans in the Senate and 48 Members of the Democratic caucus (including the two Independents who vote with the Democrats). Republicans would need at least 50 votes in support of any action or legislation to proceed – Vice President Mike Pence would be called upon to break any tie votes. Several Republicans had already expressed serious reservations about various provisions of the bills under consideration.
Monday, July 24:
Senator John McCain (R-AZ) made the surprise announcement that he would be returning to Washington DC, despite his recent brain surgery and cancer diagnosis.
Tuesday, July 25:
The Senate voted on the “Motion to Proceed” on debate of the repeal of the ACA. This is a procedural voted needed to begin debate on the bill. With Vice President Pence casting the vote to break the tie, the motion passed the Senate 51-50. Senator Susan Collins (R-ME), Senator Lisa Murkowski (R-AK) and all Democratic Caucus Senators voted no.
Following the successful motion to proceed, the Senate voted to replace the House-passed text with it’s own text, a version of the Better Care Reconciliation Act
- This bill included an amendment by Senator Ted Cruz (R-TX) that would allow insurance companies to sell plans that do not comply with current insurance regulations as long as some of their plans do comply. Insurers could drop maternity care, mental-health treatment, and other benefits if they sell at least one health plan that includes them.
- This bill also included an amendment by Senator Rob Portman (R-OH) which would provide $100 billion to help people cover their deductibles and other expenses when they lost Medicaid coverage, and it would let states set up such arrangements without needing special federal approval.
Due to an opinion by the Senate parliamentarian, this bill would have required 60 votes to pass. With 57 “no” votes and 43 “yes” votes, the BCRA did not pass. The no votes were cast by Senators Murkowski (R-AK), Collins (R-ME), Heller (R-NV), Corker (R-TN), Cotton (R-AR), Graham (R-SC), Lee (R-UT), Moran (R-KS), Paul (R-KY), and the whole Democratic caucus.
Wednesday, July 26:
Following the defeat of the BCRA, the Senate held a vote on the Obamacare Repeal Reconciliation Act, a “repeal and delay” bill. This bill failed with 55 no votes and 45 yes votes. The no votes were cast by Senators Murkowski (R-AK), Collins (R-ME), Heller (R-NV), Alexander (R-TN), Capito (R-WV), Protman (R-OH), and the whole Democratic caucus.
Thursday, July 27 into Friday, July 28:
At around 10:30 pm Thursday, Majority Leader McConnell introduced the language of what had been called the “skinny repeal.” Officially titled the Healthcare Freedom Act, this bill would have struck down a few provisions of the ACA, including the individual mandate, the employer mandate, and the medical device tax. The Congressional Budget Office (CBO) reported that the Health Care Freedom Act would cause 16 million people to lose insurance and individual market premiums to go up by 20 percent. The insurance coverage provisions would have also resulted in a loss of $235 billion in the Medicaid program over 10 years.
At about 1:30 am Friday morning, the final vote on the Senate series of repeal efforts was completed with a defeat of the Health Care Freedom Act by a vote of 51-49, with Senators Collins (R-ME), Murkowski (R-AK), McCain (R-AZ), and the whole Democratic caucus voting against the bill.
What We Narrowly Avoided:
If the Health Care Freedom Act had passed the Senate, a joint House-Senate conference committee would have considered the Health Care Freedom Act and the House-passed American Health Care Act (AHCA) to develop a bill to be considered by both the House and Senate. Through the AHCA, per capita caps and over $830 billion in cuts to Medicaid over a decade would have been part of the consideration by the conference committee. The House also could have simply passed the “skinny repeal” without going to conference. Both of these scenarios were of major concern to many Senators and were a factor in decisions to oppose the bill.
The Arc of the United States released statement on the failure of the effort to repeal the Affordable Care Act (ACA) and make fundamental structural changes to the Medicaid program which can be seen here.
Several Senators have already announced efforts to work together to produce legislation to address issues left in limbo by the failure of the House and Senate efforts. Some are looking to work in a bipartisan manner to ensure that the affordability provisions in the ACA remain funded and to address health insurance market place issues. House Minority Leader Nancy Pelosi (D-CA) wrote to House Speaker Paul Ryan (R-WI) and Senate Majority Leader McConnell indicating that “we have a responsibility to pivot from the current debate on health care and to work in a bipartisan fashion to lower costs, improve quality, and expand coverage, while strengthening the stability of the marketplaces.” Senate Minority Leader Chuck Schumer (D-NY) has similarly expressed a desire to work in a bipartisan manner to resolve the identified problems of the ACA.
As Congress continues to debate health care policy, The Arc and other disability advocates expect to remain fully engaged. In the meantime, sincere thanks and acknowledgement are due to the extraordinary efforts of people with disabilities and their families, friends, supporters, and providers throughout the country who shared their life experiences and made their voices heard on the issues of affordable, accessible health care and the critical importance of home and community based services and health care through Medicaid. This work over the last nine months clearly affected elected officials. It was a powerful combined effort and it helped force the defeat of misguided attempts to repeal the ACA and cut and cap the Medicaid program.
Last week, the House and Senate advanced the most important spending bills for disability programs – Labor, Health and Human Services, Education, and Related Agencies (L-HHS-ED). Both would maintain overall sequestration funding levels and include a number of substantial cuts to programs, earning the promise of a veto by President Obama.
L-HHS-ED – Senate – The Senate bill passed the Appropriations Committee along party lines on June 25. The bill’s discretionary funding level is $3.6 billion below the Fiscal Year (FY) 2015 enacted level and includes numerous policy riders that would limit the activities of federal agencies. Several federal agencies would receive significant cuts and a small number would receive increases. Notable examples include:
- LABOR: Includes a 4% cut for Workforce Innovation and Opportunity Act (WIOA) programs.
- HHS: Includes a 28% cut for the Centers for Medicare and Medicaid Services (CMS) program management that would restrict the agency’s ability to operate the Affordable Care Act programs, Medicare, and Medicaid.
- EDUCATION: Includes a $1.1 billion cut for the Department. However, the IDEA state grant program would receive a nearly 1% increase.
L-HHS – House – The House bill passed the full Appropriations Committee along party lines on June 24 and would provide discretionary funding at $3.7 billion below the FY 2015 level. The bill also includes numerous policy riders. The House bill included spending cuts and select increases similar to those in the Senate bill:
- LABOR: Includes a 2% cut for the Employment and Training Administration that helps to implement Workforce Innovation and Opportunity Act (WIOA) programs.
- HHS: Includes a $344 million cut for CMS.
- EDUCATION: Includes a cut of $2.8 billion to the Department of Education. However, this includes an increase of $12 billion (4.3%) for IDEA grants to states.
See the funding levels for specific disability related programs.
The U. S. Supreme Court upheld the Affordable Care Act (ACA) again in deciding King v. Burwell. The justices, in a 6-3 ruling, said that Congress intended for federal subsidies to be available in every state, regardless of whether the state created its own marketplace. The Arc applauded the decision as a major victory for people with disabilities and others who need access to affordable health care.
The ACA is important to people with disabilities. It expanded coverage and reformed insurance to end discrimination against people with disabilities and enhance access to health care. The private health insurance marketplaces allow individuals or small businesses to shop for coverage and potentially receive subsidies to help offset the cost of insurance. The subsidies are key to ensuring affordable coverage. The health insurance reforms, the protections from high premium increases or out-of-pocket costs, and the coverage of “essential health benefits”, including mental health care and rehabilitative/habilitative services and devices, help assure that people with disabilities have affordable health care that meets their needs. To read The Arc’s statement visit our blog.
The House Appropriations Subcommittee on Labor, Health and Human Services, Education, and Related Agencies (L-HHS-ED) approved its Fiscal Year 2016 appropriations bill on an 8-4 party line vote. Funding for these agencies is reduced by 2.5% overall with cuts mostly targeted on the Affordable Care Act, family planning, and the Agency for Healthcare Research and Quality. Disability-related programs were largely level funded, and one received a sizable increase – the Individuals with Disabilities Education Act (IDEA) grants to states. The IDEA state grant would receive an increase of 4.3% over the 2015 funding level, bringing the federal share of the additional cost of providing special education from 16% to 17%. A detailed funding chart will be provided when more detailed line item funding is made available by the committee. The full House Appropriations Committee markup is scheduled for tomorrow and the Senate L-HHS-ED Subcommittee will take up their bill later this week.
Rep. Tom Price (R-GA), Chairman of the House Budget Committee, released the proposed House FY 2016 Budget Resolution on March 17. The measure was passed by the Budget Committee the next day. While Congressional budgets are merely blueprints, they set the tone for spending and revenue priorities. The proposed House budget would cut overall spending by $5.5 trillion and reduce revenues by at least $1.5 trillion over 10 years. Included in the spending cuts are combined cuts to the Medicaid program of $1.8 trillion. The proposed budget contains numerous specific provisions that would be devastating for vulnerable populations, including people with disabilities. Prime among these are:
- Medicaid. The House budget would cut Medicaid by $913 billion over 10 years through “flexible state allotments,” resulting in a cut of more than 30 percent by 2025. The federal government would no longer pay a fixed share of states’ Medicaid costs, starting in 2017. Instead, states would get a fixed dollar amount known as block grants or “state flexibility funds” (the process for determining the amounts of these funds is not specified).
- Repeal of the Affordable Care Act (ACA), including Medicaid expansion. The Affordable Care Act (ACA) expanded Medicaid to cover people with incomes up to 133% of the poverty level ($15,654 for an individual). The proposed House budget would repeal the ACA, resulting in millions of people losing access to health care.
- Medicare. The House budget would fundamentally restructure the Medicare program, including privatization and over $100 billion in spending cuts over 10 years.
- Discretionary Programs. Non-defense discretionary programs would be cut starting in 2017. The total 10 year cut would be $759 billion, or 14 percent below the current caps. Included in this category are many disability related programs such as housing, education, employment, transportation, and protection and advocacy.
- Social Security. The House budget would cut benefits for Social Security Disability Insurance (SSDI) beneficiaries who also receive Unemployment Insurance because they have attempted to work, but lost their job through no fault of their own. It also reiterates a provision in the House rules for the 114th Congress that sets up hurdles to a routine replenishment of Social Security’s disability fund, needed to prevent across-the-board SSDI benefit cuts at the end of 2016. Finally, the House budget recommends establishing a commission to look at Social Security’s long term finances.
Senator Mike Enzi (R-WY), Chairman of the Senate Budget Committee, released the proposed Senate FY 2016 Budget Resolution on March 18, one day after the release of the House Budget. In a party-line vote, the Senate Budget Committee passed the measure on March 19. The proposed Senate budget provides for a slightly smaller overall spending cut goal of $5.1 trillion over 10 years, with $4.3 trillion cut from mandatory programs and $97 billion from discretionary programs. The combined Medicaid cuts would exceed $1.3 trillion over ten years. Specific provisions of great concern to the disability community are:
- Medicaid. The Senate budget would radically restructure Medicaid by converting much of it into two block grants (no information is provided on how the funding levels would be set). It “improves Medicaid based on the CHIP model” and “increases state flexibility in designing benefits and administering its programs, to encourage efficiency and reduce wasteful spending” for long term services and supports. (Fortunately, it makes no changes to the funding of acute care services for the low-income elderly and persons with disabilities.)
- Repeal of the ACA, including Medicaid expansion. The Senate budget seeks to repeal the ACA.
- Medicare. $435 billion in Medicare savings is proposed, none of it specified.
- Discretionary Programs. The Senate budget “strengthens the caps” on discretionary spending. It would maintain full sequestration in 2016, and cuts funding for non-defense discretionary programs at least $236 billion below the sequestration levels through 2025. By 2025, total funding for non-defense discretionary programs would be at least 24 percent below the 2010 level adjusted for inflation.
Open enrollment for health insurance offered through the marketplaces ended February 15, 2015. Extra time is allowed for people who started the enrollment process but did not finish. There are also special enrollment periods for people who lose their health coverage or experience another qualifying change in their situation. The administration is reporting that 11.4 million people signed up or were re-enrolled for health insurance during the open enrollment period. For more information about health insurance visit: https://www.healthcare.gov.
Open enrollment for health insurance marketplaces under the Affordable Care Act ends February 15. This is an opportunity for people who do not have health insurance to purchase it. There is also help with paying the costs of health insurance for low and moderate income individuals. To learn more about what is available in your state visit the health care website.