There was talk of bipartisanship on healthcare during Tuesday’s Senate Finance Committee hearing about “issues impacting cost and coverage.” Some areas of potential agreement appeared on the horizon, including ideas about lowering drug costs and stabilizing the state insurance markets. But the talking points of Democrats and Republicans on major long-term issues still seemed irreconcilable, and the latter continued threatening to repeal the Affordable Care Act (ACA).
In his opening statement, Senator Orrin Hatch (R-UT), the committee chair, blasted the ACA, saying that it hadn’t reined in costs and was driving up premiums for many people who buy insurance on the state exchanges. He was dubious about the idea of trying to fix the law.
Alluding to the cost-sharing subsidies that some experts believe must be paid to insurers to stabilize the exchanges, he said, “In my view, an Obamacare bailout that is not accompanied by real reforms would be inadvisable. We can’t simply invest more resources into a broken system and hope that it fixes itself over time.”
However, Senator John Thune (R-SD), who is part of the Senate leadership and an advocate of ACA repeal, said later in the hearing that he supports “moves to stabilize the insurance markets while reform efforts continue.”
“Pouring Gasoline on the Fires”
Senator Ron Wyden (D-OR), the ranking member of the committee, said in his opening statement that President Donald Trump “is pouring gasoline on the fires of uncertainty in the private [insurance] market.” Among other things, he said, the president is forcing insurers to raise rates by refusing to say whether he will cut off the cost-sharing payments that the ACA guaranteed them. Also, he said, the administration is badmouthing the law and making it harder for people to enroll in the exchanges. Many states, similarly, have tried to weaken the insurance markets while leaving millions of people in the lurch by refusing to expand Medicaid, he said.
Wyden said he favored using Section 1332 of the ACA to give states the flexibility they need to adjust the law to their own conditions. Some states, he noted, are considering the use of Section 1332 to launch state-based reinsurance programs; others want to build single-payer systems. “The bottom line is that 1332 is all about giving the states the chance to do better, but not worse,” he said.
Cassidy-Graham-Heller
The latest ACA repeal-and-replace bill, cosponsored by Senators Bill Cassidy (R-LA), Lindsay Graham (R-SC), and Dean Heller (R-NV), proposes going beyond Section 1332 to allow states to design their own programs for the individual market. This measure was a major focus during the question-and-answer portion of the hearing.
First, Heller asked Avik Roy, cofounder and president of the Foundation for Research on Equal Opportunity, a conservative think tank, what he thought of the legislation. Roy said he believes in state flexibility but also would like to give individuals more flexibility in choosing the kind of insurance coverage and healthcare they want.
Cassidy asked Andrew Slavitt, former acting administrator of the Centers for Medicare and Medicaid Services, whether Section 1332 would allow a state to obtain a waiver that covered both individual insurance and Medicaid. Slavitt said that states could do that, but that they’re not allowed to take money out of Medicaid for other purposes.
The discussion turned back to the Cassidy-Graham-Heller bill later on, when Senator. Benjamin Cardin (D-MD) said that it might make sense to give states more flexibility, but not if that meant removing “guardrails” that guarantee people a certain level of insurance coverage. Slavitt agreed, pointing out that the ACA provides a lot of flexibility but that states can’t use that to reduce coverage.
Senator Robert Casey (D-PA) said he was strongly opposed to the Cassidy bill’s reduction in federal support for Medicaid, which was also a focal point of earlier Republican repeal efforts. He then asked Aviva Aron-Dine, senior fellow and senior counselor with the Center on Budget and Policy Priorities, a liberal think tank, about her views on the Cassidy-Graham-Heller bill.
Aron-Dine responded that for state flexibility to benefit people there must be resources available, cost sharing with the federal government, and standards that protect consumers. In the Cassidy-Graham-Heller proposal, she said, “Those standards aren’t met, and therefore the consequences would be very similar to the previous [Senate] repeal bill.”
The measure, she said, would eliminate the ACA’s Medicaid expansion and all insurance subsidies for individuals. “So it would go beyond the previous Senate bill and leave working people with no guarantee of assistance in the individual market. And it would completely overhaul the Medicaid program. In place of expansion and subsidies, states would be left with a block grant that provides fewer resources, doesn’t address any unexpected costs…and would redistribute [the federal funds] across states in ways that would leave some states with even deeper cuts.”
Two Groups in Exchanges
Much of the discussion about how to fix Obamacare focused on middle class people who are forced to buy individual coverage through the insurance exchanges. While less affluent people are heavily subsidized, those who make more than 400% of the federal poverty level get no subsidies, and in many cases are “paying through the roof” for insurance, said Roy.
Edmund Haislmaier, a senior research fellow at The Heritage Foundation, noted that about two-thirds of exchange enrollees are lower-income individuals, many with above-average medical needs. This has resulted in a risk pool with a lot of high-risk people, and he said he didn’t expect insurers that have exited the exchanges to return.
On the other hand, Haislmeier said in response to a question from Heller, other insurance companies that are experienced in Medicaid will move in to fill the gap in the market, especially in rural areas. “If you’re the only carrier, you can charge what you want, because the government pays most of the cost,” he said.
Along with the hearings on market stabilization that the US Senate Committee on Health, Education, Labor and Pensions has held in the past 2, today’s Senate Finance Committee hearing offered a marked contrast to the earlier approach of the Senate leadership, which formulated its healthcare bill in secret.
“We need more hearings like this,” declared Senator Tom Carper (D-DE). “This should be about regular order and bringing in evidence for and against.”
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