Congress Temporarily Averts Shutdown

Earlier this afternoon, both the House and Senate passed a one week extension of federal funding in order to avoid a shutdown and continue negotiations on the FY17 spending package.

With a deal on the FY17 spending package in sight, leaders in both chambers of Capitol Hill passed the short-term extension earlier today to give themselves more time to finalize negotiations before the new deadline ‒ Friday, May 5. This bipartisan act of good faith will ensure that Congressional Democrats, and Republicans on Capitol Hill and in the Trump administration, have enough time over the next seven days to settle the few remaining areas of disagreement. Two of the largest roadblocks to an agreement, President Trump’s $1.5 billion request for border wall funding and Democrats’ demand for $7 billion for CSR subsidies, were stripped out of the negotiations earlier this week and will both be negotiated away from the spending package. The bill does, however, provide a temporary extension of coal miners’ health benefits through Friday, May 5. For now, leaders in Washington are focused on finding agreement on several less contentious provisions of the FY17 spending package.

We’ll continue to provide timely updates over the next week as Congress and the Trump administration work towards a bipartisan, long-term extension of funding  that provides certainty, stability, and predictability for health centers.

Avoiding a Shutdown, Resurrecting AHCA, and Closing Out the Wicker-Stabenow Health Center Funding Letter

By: Oliver Spurgeon, Deputy Director, NACHC Federal Affairs

The halls of Capitol Hill are buzzing this week as Congress returns from the two week Easter Recess, President Trump and Congressional Democrats continue negotiations to keep the federal government open beyond Friday, April 28, the Wicker-Stabenow Health Center funding letter closes, and House Republicans consider bringing the American Health Care Act back from the dead.

We here at Health Centers on the Hill want advocates to be up to date on all the latest developments. To that end, you can get a more in-depth look at these and other policy issues impacting health centers by joining our April Policy and Advocacy Webinar, this Wednesday at 3:30 PM eastern. Click here to register.

Shutdown Fight

With just three days left to negotiate a deal before the federal government shuts its doors and temporarily suspends nonessential services on Friday at midnight, Democrats on Capitol Hill and the Trump administration have yet to find agreement on the remainder of the FY17 spending package. At issue for the Trump administration and Congressional Democrats, respectively, are a $1.5 billion down payment to begin construction of the southern border wall, and $7 billion to fund cost sharing reduction (CSR) payments for participants in the federal healthcare exchanges with incomes below 250% of the poverty level. For more on CSR payments and their role in marketplace coverage, see a recent post here on our sister blog, The Policy Shop.

Until the inclusion of recent demands to fund the border wall and continue CSR subsidies for health exchange enrollees, Congressional leaders were able to iron out roughly 200 controversial provisions in the FY17 continuing resolution. Congressional leaders in both parties were able to put partisan affiliations aside to avoid the traditional political stumbling blocks of Planned Parenthood funding and budget cuts at various federal agencies, including the Environmental Protection Agency and State Department, which have held up previous negotiations. However, the recent addition of border wall funding and CSR payments have left Congressional Democrats and the Trump administration at loggerheads.

Most recently, Mick Mulvaney, the Director of the Office of Management and Budget OMB and President Trump’s chief negotiator on the FY17 spending package, proposed a dollar-for-dollar exchange to fund both the border wall and CSR subsidies; however, that offer has drawn sharp rebuke from Congressional Democrats who support a permanent extension of the CSR payments. We’ll continue to send out updates this week negotiations between the Trump administration and Congressional Democrats progress. Please keep an eye on NACHC’s social media accounts and blog for up-to-the-minute news about the FY17 spending package.

****Editor’s Note****

 

Negotiations between the Trump administration and Congressional Democrats are still ongoing, showing glimmers of a possible breakthrough to avert a government shutdown before Friday’s midnight deadline. President Trump’s $1.5 billion request for border wall funding has been rescinded ‒ removing one of the largest obstacles leaders in Washington faced to strike an agreement that keeps the federal government open.

However, a deal isn’t guaranteed. As of Wednesday afternoon, Republicans and Democrats are still wrestling with several issues including $7 billion for CSR subsidies, at least a $15 billion increase in defense funding, $500 million to alleviate Puerto Rico’s looming Medicaid crisis, and $1.3 billion for coal miners’ health benefits. At Wednesday’s morning press briefing, Speaker of the House Paul Ryan suggested that the $7 billion for CSR subsidies have no place in Congress’ annual spending bills ‒ implying that the Trump administration, and not Congress, is responsible for funding them. As we move closer to Friday’s midnight deadline, it looks increasingly likely that Congress will pass a week-long extension in order to reach a deal next week.

 

****End Note****

Wicker-Stabenow Health Center Funding Letter

If Friday’s shutdown drama doesn’t provide enough excitement for you, there’s also another deadline on the horizon: the Wicker-Stabenow Health Center Funding Letter closes out Thursday, April 27. Currently, 46 Senators have signed on board to support health center funding in FY18; but that’s still well short of the 62 who joined last year. (Click here to see if your Senator has signed, or if he/she signed last year but not yet this year) We need your help to make sure Congress knows the importance of ending the health center funding cliff well before September 30, and why providing robust funding for health centers in FY18 is important. Click here to send a note to your U.S. Senators and ask them to add their names to the Wicker-Stabenow Health Center Funding Letter.

Reviving the American Health Care Act

House Republicans spent much of the Easter Recess discussing potential changes to their Affordable Care Act repeal bill, the American Health Care Act, which failed to receive a vote on the House several weeks ago. In a concerted effort to bring additional members of the House Freedom Caucus on board the American Health Care Act, Rep. Tom MacArthur (R- NJ) proposed an amendment to relax many of the ACA’s current consumer protections. Specifically, it would allow states to opt out of certain ACA requirements that everyone be charged the same amount for health care coverage, regardless of their health status. In exchange for waivers, states would be required to establish a new risk-sharing program to help cover the sickest and most costly patients, who could be denied coverage by insurers due to the waiver.

Lastly, a change made to the bill before Congress departed for the Easter Recess provided $15 billion for states to establish their risk-sharing programs; however, a recent analysis of Rep. MacArthur’s proposal suggests states will need between $3.3 billion and $17 billion each year in order to make the proposal viable. Long story short, Rep. MacArthur’s amendment is expensive!

House Republicans have yet to decide whether to move forward with Rep. MacArthur’s amendment, and several moderate Republican members of the House of Representatives have already expressed concerns about the potential impact, and cost, of removing health care protections for vulnerable Americans.

Wrapping Up

Although progress on the House ACA repeal effort is expected to grind to a halt this week due to Congress’ focus on the looming government shutdown, the Federal Affairs team here at NACHC will continue to publicly express the importance of immediately fixing the health center funding cliff, preserving the structure and integrity of Medicaid, and providing predictability for health centers. Click here to read NACHC’s statement on the American Health Care Act, and please continue to follow our activities on Twitter and Facebook for the latest updates on the House’s ACA repeal effort.

In dramatic fashion, House leaders pull ACA Repeal and Replace Bill

What a week it was last week. Even as our staff here at NACHC has been pulling together the finishing touches for the 2017 Policy and Issues Forum (sure to be our best yet, by the way) last week was a roller coaster in terms of the future of major health reform legislation that was working its way through the House.

  • On Monday, it was clear that the bill House Republicans had initially introduced on March 6th didn’t seem to have the votes necessary for passage. Side deals with individual members were being cut, most notably the so-called “Buffalo Buyout,” championed by Rep. Chris Collins of New York, which was a direct appeal to win support from several members of upstate New York. Additional changes included the addition of an optional block grant and work requirement for states in the Medicaid program.
  • On Tuesday, the horse-trading continued in private meetings between the administration and Congressional members, with President Trump warning Congressional Republicans about the electoral ramifications of a failure to pass the bill by the target date of Thursday the 23rd – a symbolically important day for the President and the Leadership, as it marked 7 years to the day since the signing of the ACA.
  • On Wednesday evening, the drama heightened as members of the conservative House Freedom Caucus made a late deal with the administration to add additional changes to the bill – most notably provisions to repeal the so-called “Essential Health Benefits” provisions from the ACA, which outlined those services all individual market plans must cover under the law. The House Rules Committee met for 13 hours to prepare the bill to move to the floor.
  • Yet by Thursday it had become clear that even those last-minute changes were not enough to sway the votes of all members of the Freedom Caucus, many of whom continued to proclaim their opposition to the bill, and demand even further changes to the ACA. At the same time, more moderate House Republicans, most notably Charlie Dent of Pennsylvania, chair of the so-called “Tuesday Group” of moderates, were announcing their own opposition in light of the last minute changes. It became clear by mid-afternoon that the anniversary date would not be met, and the leadership decided to hold the bill until Friday.
  • Thursday night, President Trump issued an ultimatum to House members, saying that negotiations had ended, the bill would go to a vote, and if it failed, the administration was prepared to leave the ACA in place and move on.
  • Despite some last minute signals of new support, by mid-afternoon Friday the outcome was becoming clear -and at 4pm, Speaker Paul Ryan stepped to a podium and announced that the bill was being withdrawn, not having found the votes to pass it successfully.

As advocates are aware, NACHC had expressed some major concerns with the legislation, both in the form of a public statement and action alert, and in direct conversations with members and staff on the Hill. Yet while the provisions – mostly dealing with Medicaid changes – that gave us greatest concern will likely not be moving forward legislatively in the near future, it’s critical that all health center advocates know that we’ve only just begun the nationwide fight to make sure our centers and our patients can survive and thrive in this new environment.

That will be a theme that those 2,500+ advocates who are travelling to DC this week for the Policy and Issues Forum will hear over and over. Our policy and advocacy work must extend beyond Capitol Hill, into the new administration, state legislatures, governor’s offices and beyond. The opportunities health centers face – and the threats – are making themselves clear at EVERY level of government, and true advocacy success will mean being engaged at each of these levels.

 

First Look: House Releases ACA “Repeal and Replace” Bill

Last night around 6pm, the Congressional effort to repeal and replace the Affordable Care Act entered a new phase, as House Republicans released the draft legislative text of their proposal. The legislation will be considered this week by the two primary committees with jurisdiction over health care – the Energy and Commerce Committee and the Ways and Means Committee. The draft text and section-by-section summaries are linked below.

In the coming days, NACHC will have more in-depth analysis and public statements regarding the bill and the effect it may have on health centers and our patients. As discussed on past webinars and in our materials and talking points, a major focus of that analysis will be on proposed changes the bill makes to the Medicaid program, which covers nearly half of all health center patients and is a crucial source of revenue that supports ongoing operations. In the meantime, however, we wanted to provide advocates with a basic summary of what the bill contains.

One note of caution – we expect the language of this legislation to continue changing throughout the process, both as amendments are added in Committee and as the Congressional Budget Office (CBO) and others release analysis of what the bill would mean. That said, here are some of the basics:

Medicaid

  • The ACA Medicaid expansion, which has been adopted in 31 states and Washington, D.C., would end on December 31, 2019. At that point, expansion beneficiaries would remain enrolled, but would become ineligible if they drop out of the program for 30 days.
  • Beyond the changes to the expansion population, the bill also proposes a major overhaul of how Medicaid is structured and financed. Instead of the current open-ended federal entitlement, states would get capped payments based on the number of Medicaid enrollees in different categories (Elderly, Blind, Disabled, Children, Expansion Adults, Non-expansion Adults), which would grow over time but not necessarily as fast as the cost of delivering care.
  • The bill allocates $10 billion over 5 years to be used to raise payments to Medicaid providers in non-expansion states.
  • The bill does not propose any change to the current FQHC Prospective Payment System (PPS) or the required FQHC services under Medicaid. Indeed, because of some of the parliamentary rules surrounding the bill, very little of the “state flexibility” sought by governors and others is included in the proposal.

Private Insurance/Exchanges

  • The bill would create age-based tax credits for the purchase of insurance, ranging from $2,000 to $4,000, replacing the Affordable Care Act’s income-based subsidies. Credits for a single household would be limited at $14,000. Subsidies would be phased out for higher-income Americans – for individuals earning $75,000 and at $150,000 for families.
  • The bill would end the penalty for both individuals who don’t have health insurance (the “individual mandate”) and employers who don’t offer it (the employer mandate).
  • Even though the individual mandate is effectively eliminated, the bill does contain a new requirement that individuals maintain continuous coverage or face a financial penalty the next time they obtain insurance. A person whose coverage lapses would have to pay a 30 percent surcharge on premiums for a year when they sign up again.
  • Starting in 2018, the proposed bill would eliminate many of Obamacare’s taxes, including those on prescription and over-the-counter drugs, tanning services and health savings accounts.
  • The bill also includes $100 billion for state grants aimed at stabilizing the individual market over 10 years. States could use this money to create reinsurance programs or high-risk pools to cover the costs of the sickest, most expensive customers.
  • The House plan would also let insurers charger older customers more, while dropping costs for younger customers. Currently, insurers can charge their oldest customers no more than three times as much as younger enrollees, but the House plan increases that to a five-to-one ratio.

Again, we’ll plan to have more analysis, detail and reaction as the process unfolds. At this stage, despite now having more detail than we’ve had up until this point, key questions remain unanswered – questions that will shape and determine the outcome of the legislation. First, how much does the bill cost and what impact will it have on the number of people with insurance? That information will be determined by the CBO, and Congressional leaders have pledged to have those questions answered by the time the bill moves to the floor. Second, does it have the votes needed to pass? Both House conservatives and Senate moderates expressed their concerns about the bill yesterday. Margins are very close in both chambers, and no Democrats are expected to support this effort – meaning Congressional leaders can only afford a small handful of “no” votes on their side for the bill to stand a chance of passage.

Want to watch the legislative process in action? Both Energy and Commerce and Ways and Means will webcast their legislative markups on their respective Committee websites, starting Wednesday at 10:30 AM.

As Congress Returns, Leaks, Rumors and Disagreements Dominate the ACA Debate

By Oliver Spurgeon and John Sawyer, NACHC Federal Affairs Team

Normally, a Congressional recess, where Members travel home to hold meetings with constituents in their districts, is a relatively quiet time for those of us in Washington. Staffers on the Hill don jeans in lieu of suits, and may pull back to working 8 or 10-hour days, rather than the typical 12+. For those of us following the health care debate in Washington closely, however, last week’s recess was anything but boring.

Friday morning, a leaked and dated draft of House Republicans’ budget reconciliation bill ‒ their initial ideas to repeal the Affordable Care Act (ACA) ‒ landed in inboxes across Washington as lobbyists and staffers were finishing their morning coffee. Judging by the crooked pages, missing page numbers, and numerous pen scribbles throughout the document, the effort is far from complete. Yet after almost 7 years of Congressional pledges to “repeal and replace” the Affordable Care Act (ACA), and roughly two months of relative inaction on Capitol Hill, the draft bill does provide more detailed insight into thinking amongst House leaders than had previously been available. The bill would roll back the ACA Medicaid expansion, replace the ACA premium subsidies (which are determined based on income) with tax credits based on age, make funds available to States to create high-risk pools or other “innovations,” and would attempt a major structural change to the Medicaid program – shifting away from the current entitlement structure to one where federal contributions are capped. A good summary of the provisions is available on Health Affairs’ blog here.

Yet the leaked draft was also quite dated, with a date-stamp indicating it was current thinking as of February 10th. Two weeks is a lifetime in politics, as they say – and the same goes for complex legislation. This rule of thumb definitely applies as bills get more complex, and can often result in first drafts and final products that are miles apart in terms of content and outcomes. The 2009-2010 effort to pass the ACA is a testament to that rule. Remember, after 15 months of debate ‒ passing a major bill through Congress was and still is a slow and tedious process ‒ the House’s initial draft of the ACA and the version signed into law looked nothing alike.

Friday also marked the beginning of the annual meeting of the National Governors Association here in Washington. Considering how intertwined the ACA is with state-level policy and politics, the nation’s Governors are expected to be among the most important voices as Congress considers health policy this year. So what emerged from the Governors discussions? More disagreements, even among the majority Republican governors, and more leaks.

Medicaid seems to be the main flashpoint, understandably, for the governors. Specifically, documents leaked to vox.com and subsequent reports suggest that Republican governors are still in very different places from one another when it comes to the Medicaid expansion question, and the details of proposed structural changes like a per-capita cap or block grant. Disagreement among governors tends to make especially Senators very hesitant, since mostly Senators don’t like to go against their own state’s governor – especially when they come from the same party.

On the eve of Congress’ return, more disagreements came into the open. On Monday night, Rep. Mark Walker (R-NC), Chair of the conservative House Republican Study Committee, and Rep. Mark Meadows (R-NC), Chair of the even more conservative House Freedom Caucus, both announced that they could not support the House bill if it resembles the leaked draft. Together, Walker and Meadows represent well over 100 members of the House Republican Conference. So, without Democratic support, no bill is likely to pass if either of these groups is opposed, much less if both of them are.

All of this taken together suggests that Congress is actually quite a bit further from resolving the “repeal/replace” issue than anyone initially thought. If you need further proof that Congress remains in the starting blocks on healthcare reform, just look at of all the organizations still providing ideas to Republicans and Democrats in the House and Senate. Doctors and hospitals continue to beat the drum of patient access, and insurers, drugmakers and governors are all amongst those visiting with the Trump administration over the last couple of weeks. And of course, health centers are still weighing in with everyone involved in this process to highlight and promote the value and impact of our national system of care.

Bottom line? While we need all advocates to stay engaged in the debate (check out our fabulous new advocacy website, www.hcadvocacy.org for any number of ways to do so), it’s also vital that we stay focused on the health center message, and that we not bet the farm on leaks, rumors, or innuendo. In the meantime, the Federal Affairs team here at NACHC will continue to monitor developments on the Hill, and ensure that the voices of health centers are represented at the negotiating table. Continue to follow Health Centers on the Hill for future updates, plan to join us for the next monthly Policy and Advocacy Webinar on March 21st, and most important, come make the case in person during the 2017 NACHC Policy and Issues Forum.

If you have any additional questions, comments, or concerns, or just want to learn a little more about buzzwords like “per capita caps” and “block grants,” please feel free to contact us at federalaffairs@nachc.org.