Senate Republican Leadership Releases Revised ACA Repeal and Replace Bill

Today, the Senate Republican leadership released a revised version of a bill to repeal and replace the Affordable Care Act (ACA). The new bill draft includes an amendment sponsored by Sen. Cruz (R-TX) that permits insurers to offer health insurance plans on the ACA exchanges that do not cover the ACA’s 10 essential health benefits (EHB) as long as they offer at least one other plan that provides full coverage of EHB’s. The bill also includes more funding for opioid addiction and for state initiatives to reduce insurance premiums and additionally, some flexibility for state Medicaid funding in the event of a public health crisis. The bill must still receive a cost estimate from the Congressional Budget Office (CBO), which will include the impact of the bill on insurance coverage levels, expected out Monday. The ATS remains deeply concerned about the bill because under the Cruz proposal, insurance coverage costs for people with pre-existing conditions would soar, leaving coverage unaffordable for many people with chronic respiratory conditions. The Senate leadership aims to begin voting on the bill by the middle of next week in an open amendment process, so changes could be made to the bill with subsequent votes occurring quickly.

Just before the revised leadership bill was introduced, Sen. Graham (R-SC) and Cassidy (R-LA) released their own ACA repeal and replace bill, which focuses on sending ACA funding directly to the states, rather than the federal government and would preserve more state Medicaid funding. The Graham/Cassidy proposal would also permit states to waive the ACA’s EHB’s although full details of this bill are not yet clear and some aspects are still under revision.

Despite the release of the Senate leadership’s new bill, it is still not at all clear whether it will gain the support of all Senate Republicans, a number of whom have concerns with the funding reductions to Medicaid.

Nuala S. Moore

American Thoracic Society

Washington, DC USA

Cite as: Moore NS. Senate Republican leadership releases revised ACA repeal and replace bill. Southwest J Pulm Crit Care. 2017;15(1):41. doi: https://doi.org/10.13175/swjpcc092-17 PDF

Limited Choice of Obamacare Insurers in Some Parts of the Southwest

The New York Times is reporting that all of Arizona, much of Nevada, and portions of Utah and Colorado will have only one insurer available under the Affordable Care Act (ACA, Obamacare) marketplace (Figure 1) (1).

Figure 1. New York Times compilation of insurance company announcements for providing coverage under the ACA or Obamacare.

About 35,000 people buying insurance in Affordable Care Act marketplaces in 45 counties could have no choice in carriers in Ohio and Missouri (Figure 1), This would be the first time that has happened since the marketplaces were opened in 2014.

Some insurance companies are still deciding what they will do in 2018, and others may reverse course, so these numbers could go up or down.

Most Americans get health insurance from a job or government program, but about 22 million people buy individual policies under Obamacare. More than half of them use Obamacare marketplaces, where most of them get a federal tax credit to help pay for coverage. The rest buy directly from an insurer or broker, outside the Obamacare marketplaces. A recent New York Times analysis showed that many insurers are now choosing to sell exclusively outside the marketplaces, where their customers are not eligible for federal subsidies. Because customers cannot use subsidies for these plans, many may not be able to afford coverage.

Richard A. Robbins, MD

Editor, SWJPCC

Reference

1. Park H, Carlsen A. For the first time, 45 counties could have no insurer in the Obamacare marketplaces. New York Times. June 9, 2017. Available at: https://www.nytimes.com/interactive/2017/06/09/us/counties-with-one-or-no-obamacare-insurer.html (accessed 6/12/17).

Cite as: Robbins RA. Limited choice of healthcare insurers in some parts of the southwest. Southwest J Pulm Crit Care. 2017;14(6):295. doi: https://doi.org/10.13175/swjpcc074-17 PDF 

Trump Proposes Initial Healthcare Agenda

On Friday, November 11, President-elect Trump proposed a healthcare agenda on his website greatagain.gov (1). Yesterday, November 12, he gave an interview on 60 Minutes clarifying his positions (2). Trump said that he wanted to focus on healthcare and has proposed to:

• Repeal all of the Affordable Care Act;
• Allow the sale of health insurance across state lines;
• Make the purchase of health insurance fully tax deductible;
• Expand access to the health savings accounts;
• Increase price transparency;
• Block grant Medicaid;
• Lower entrance barriers to new producers of drugs.

In his 60 Minutes interview Trump reiterated that two provisions of the ACA – prohibition of pre-existing conditions exclusion and ability for adult children to stay on parents insurance plans until age 26 – have his support (2). Other aspects of the ACA that might receive his support were not discussed.

On the Department of Veterans’ Affairs Trump proposed to make the VA great again by removing corrupt and incompetent individuals who let our veterans down (1).  The website goes on to say that only honest and dedicated public servants in the VA have their jobs protected, and will be put in line for promotions.

Several aspects of healthcare were not addressed. Universal healthcare which Trump has supported in the past was not discussed (3). Trump did not make major policy proposals for Medicare during the campaign and Medicare was not addressed on his website or during his interview.

According to a survey conducted by the Kaiser Family Foundation the top three healthcare issues concerning voters were:

• Ensuring that high-cost drugs for chronic conditions such as hepatitis and cancer become affordable;
• Lowering prescription drug costs in general;
• Making sure health plans have enough physicians and hospitals in their networks (4).

None were addressed on Trump's website or during his interview.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. https://www.greatagain.gov/policy/healthcare.html (accessed 11/14/16).
2. CBS News. President-elect Trump speaks to a divided country on 60 Minutes. November 13, 2016. Available at: http://www.cbsnews.com/news/60-minutes-donald-trump-family-melania-ivanka-lesley-stahl/ (accessed 11/14/16).
3. CBS News. Trump gets down to business on 60 Minutes. September 27, 2015. Available at: http://www.cbsnews.com/news/donald-trump-60-minutes-scott-pelley/
4. Kirzinger A, Sugarman E, Brodie M. Kaiser Health Tracking Poll: October 2016. Available at: http://kff.org/health-costs/poll-finding/kaiser-health-tracking-poll-october-2016/ (accessed 11/14/16). 

Cite as: Robbins RA. Trump proposes initial healthcare agenda. Southwest J Pulm Crit Care. 2016;13(5):240-1. doi: https://doi.org/10.13175/swjpcc117-16 PDF 

Clinton's and Trump's Positions on Major Healthcare Issues

As the presidential election nears, the positions of the two major candidates on healthcare have received more attention. Both Clinton and Trump have their healthcare positions listed on their websites (1,2). Below is a table listing their positions from their websites and occasionally other sources followed by a brief discussion of each of the issues. 

Table 1. Presidential candidate positions on healthcare issues. A questions mark denotes an unclear position.

Affordable Care Act (ACA, Obamacare)

This is a major difference between Clinton and Trump. Clinton favors its retention (1). Trump favors its repeal (2).

Access to reproductive health

Clinton supports reproductive preventive care, affordable contraception, and safe and legal abortion (1). Trump's position is unclear. He currently is pro-life but would not use Federal funds for abortion (2). Federal funding for abortions us is prohibited by law (3).

Allow importing drugs to reduce costs

Both candidates favor importation of prescription drugs to reduce prices (1,2).

Block-grant Medicaid to the states

Trump block-grants asserting that "the state governments know their people best and can manage the administration of Medicaid far better without federal overhead" (2). This idea is not new with Congressional Republicans pushing for block-granting Medicaid at least since the 1990s (4) Clinton's position is unclear (1).

Coverage of poor

Both candidates favor universal healthcare including the poor (1,2).

Healthcare for illegal immigrants

Clinton favors extending healthcare to families regardless of immigration status by allowing families to buy health insurance on the health exchanges (1). Trump's website notes that providing healthcare to illegal immigrants costs us some $11 billion annually and he favors strict enforcement of the current immigration laws (2).

Healthcare savings accounts

Trump favors savings accounts which are permitted under the ACA but with restrictions (2,5). Clinton's position is unclear.

Increase access to healthcare

Both candidates favor increased access to healthcare (1,2).

Increase income tax deductions for healthcare costs

Both candidates favor increasing income tax deductions for healthcare costs but their plans are different (1,2). Trump favors full deduction of health insurance premium payments from tax returns. Clinton favors a refundable tax credit of up to $5,000 per family for excessive out-of-pocket costs.

Price transparency

Both candidates favor increased healthcare price transparency (1,2).

Public option

Clinton favors a public option (1). Trump's position is unclear.

Reduce copays and deductibles

Clinton favors reducing copays and deductibles (1). Trump's position is unclear.

Sell insurance across state lines

Trump favors insurance companies selling healthcare insurance across state lines (2). This has been a part of the platform of every Republican presidential nominee and is permitted in 5 states but insurance companies have been reluctant to sell these policies (6). Clinton's position is unclear.

References

1. Hillary Clinton for America. Available at: https://www.hillaryclinton.com/issues/health-care/ (accessed 9/6/16).
2. Donald J. Trump for President. Available at: https://www.donaldjtrump.com/positions/healthcare-reform (accessed 9/6/16).
3. Salganicoff A, Beamesderfer A, Kurani N, Sobel L. Coverage for abortion services and the ACA. Kaiser Family Foundation. September 19, 2014. Available at: http://kff.org/womens-health-policy/issue-brief/coverage-for-abortion-services-and-the-aca/ (accessed 9/6/16).
4. Dickson V. GOP's Medicaid block-grant plan won't happen while Obama's in office. Medscape. March 19, 2015. Available at: http://www.modernhealthcare.com/article/20150319/NEWS/150319877 (accessed 9/6/16).
5. Norris L. Under the ACA, can I still have an individual HDHP and an HSA? Healthinsurance.org. May 16, 2016. Available at: https://www.healthinsurance.org/faqs/i-have-an-individual-hdhp-and-an-hsa-will-i-still-be-able-to-have-them-under-the-aca/ (accessed 9/6/16).
6. Cauchi R. Out-of-state health insurance - allowing purchases (state implementation report). National Conference of State Legislators. December, 2015. Available at: http://www.ncsl.org/research/health/out-of-state-health-insurance-purchases.aspx (accessed 9/6/16).

Cite as: Robbins RA. Clinton's and Trump's positions on major healthcare issues. Southwst J Pulm Crit Care. 2016;13(3):126-8. doi: http://dx.doi.org/10.13175/swjpcc091-16 PDF

Withdraw of Insurers from ACA Markets Leaving Many Southwest Patients with Few or No Choices

Thirty-one percent of the nation’s counties are projected to have only one insurer offering health plans on the Affordable Care Act’s (ACA) exchanges next year, according to the nonpartisan Kaiser Family Foundation (1). Another 31% are projected to have only be only two. Most of the likely one-insurer counties are predominantly rural (Figure 1).

Figure 1. Estimated number of insurers participating in Affordable Care Act exchanges by county, 2017.

Particularly hard hit is Arizona where most of the rural portions of the state will have only one insurer and Pinal County will have none. Rural Nevada is similarly affected along with Utah, Wyoming, Oklahoma and much of the Southeast US.

That would give exchange customers in large areas of the U.S. far less choice than they had this year, when only 7% of counties had one insurer and 29% had two (Figure 2).

Figure 2. Net changes in number of insurers compared to 2016.

Many insurers are losing money on the health plans they sell through the exchanges. Insurance giants UnitedHealth, Humana, and Aetna have cited heavy losses as the reason for withdrawing from ACA marketplaces (2). The insurers that remain are in some cases seeking sharp premium increases for next year, trying to get back in the black amid higher-than-expected costs.

The marketplaces were supposed to hold down prices and expand choice by fostering competition among insurers. A concern when the exchanges were set up was that they might eventually reach the "tipping point". This is the point where too many sick patients with high health care costs are enrolled in the exchanges. Their high costs lead to higher insurance premiums driving the young and healthy enrollees out of the exchanges. According to the insurers the young and healthy enrollees low costs are necessary to balance out claims ledgers. President Obama has called for the creation of a public insurance option to compete alongside private plans in places where competition is limited.

References

1. Cox C, Semanskee A. Preliminary data on insurer exits and entrants in 2017 affordable care act marketplaces. Kaiser Health News. August 28, 2016. Avialble at: http://kff.org/health-reform/issue-brief/preliminary-data-on-insurer-exits-and-entrants-in-2017-affordable-care-act-marketplaces/ (accessed 8/29/16).
2. Mathews AW, Armour S. Health insurers’ pullback threatens to create monopolies. Wall Street Journal. August 28, 2016. Available at: http://www.wsj.com/articles/health-insurers-pullback-threatens-to-create-monopolies-1472408338 (accessed 8/29/16).

Cite as: Robbins RA. Withdraw of insurers from ACA markets leaving many southwest patients with few or no choices. Southwest J Pulm Crit Care. 2016;13(2):97-8. doi: http://dx.doi.org/10.13175/swjpcc085-16 PDF