With Billions In Proposed Cuts, Medicaid Waivers May Be At Risk

The health care proposal in the U.S. Senate would slash $772 billion from Medicaid in the next decade, the Congressional Budget Office said, seriously compromising services for people with disabilities.

The nonpartisan budget office said Monday that, if adopted, the Senate bill will trigger continuing disparities in federal support for Medicaid.

By 2026, annual spending on the program would be 26 percent lower than under current policy, according to the projections. And that gap would continue to compound over time.

“Despite the uncertainty, the direction of certain effects of this legislation is clear. For example, the amount of federal revenues collected and the amount of spending on Medicaid would almost surely both be lower than under current law,” the Congressional Budget Office found.

The cuts would be especially significant to people with disabilities who represent just 15 percent of Medicaid beneficiaries, but account for 42 percent of the program’s costs, according to the Kaiser Family Foundation. In addition to traditional health care services like doctor and hospital visits, Medicaid provides assistance for people with disabilities to live and work in the community.

Both the Senate bill and a version passed by the House of Representatives in May call for historic changes to Medicaid. Traditionally, the program has operated as an entitlement meaning services are provided to anyone who meets eligibility requirements, with the federal government providing matching grants to states to help cover the cost.

Under the Republican plans, however, Medicaid would shift to a per capita cap system where the federal government would provide a fixed amount for each beneficiary no matter how much their care truly costs. States would be left to make up the difference.

“With less federal reimbursement for Medicaid, states would need to decide whether to commit more of their own resources to finance the program at current-law levels or to reduce spending by cutting payments to health care providers and health plans, eliminating optional services, restricting eligibility for enrollment through work requirements and other changes or (to the extent feasible) arriving at more efficient methods for delivering services,” the Congressional Budget Office determined.

States would likely resort to a “mix of those approaches,” the budget office said.

Disability advocates have warned that home and community-based services for people with disabilities would be the first to go because they are considered optional under Medicaid policy.

“Hundreds of billions of dollars of cuts in Medicaid are never acceptable,” said Julia Bascom, executive director of the Autistic Self Advocacy Network, who indicated that the budget office’s projections are just the tip of the iceberg.

“If you look at the bill, you can see they’ve hidden the deepest cuts in the years following CBO’s 10-year window,” Bascom said. “People with disabilities cannot afford this bill."

Action Alert : Weekend Action Needed to #SaveMedicaid

Weekend Action to #SaveMedicaid SUMMARY: The Senate released its bill, the Better Care Reconciliation Act, to repeal the Affordable Care Act and to make deep cuts and caps to the Medicaid program.  This bill, if it becomes law, would have the biggest and most devastating impact on health and community services for people with disabilities in 25 years.  The Senate could pass the bill as soon as Thursday, June 29.  If this terrible bill is passed by the Senate, it could easily and quickly be passed by the House and signed into law! AUCD must join in coalition with other disability and civil rights groups in your states to educate Senators this weekend, Monday and Tuesday.  Time is of the essence! BACKGROUND: The Senate bill continues the deep cuts to Medicaid (by more than $800 billion over 10 years).  In addition, Medicaid funding would be allocated based on a per capita cap formula and the growth rate is slower than the House bill (starting in 2025).  Like the House bill, the Senate bill ends the Medicaid expansion that covered 11 million people, including those with disabilities.  The Senate bill makes it even easier than the House bill to seek waivers of essential health benefits and will lead to the return of annual and lifetime coverage limits. In sum, the Better Care Act is NOT Better but even worse for people with disabilities and all Americans. The Congressional Budget Office (CBO) is expected to release its coverage and cost estimates of the bill on Monday.  Senators would be irresponsible to vote on a bill next week without analyzing the CBO score and the impact on states and getting feedback from key stakeholders. Take Action: Call your Representative/Senator/Member of Congress: 1.      Find out where your Senators are this weekend and visit them!  2.      Find events near you on https://townhallproject.com/ 3.      Visit state offices, organize rallies, vigils, sit-ins. 4.      Call office repeatedly. Dial 866-426-2631 (toll free) and ask for the office of your Senators. Message: The Senate bill, Better Care Act, would seriously threaten health and home and community-based services and supports for people with disabilities.  ·         Before taking any action on the Senate bill, please analyze the Congressional Budget Office (CBO) estimates on coverage and cost . ·         This bill massively shift costs onto states, which will be forced to either raise taxes and/or severely restrict access to services that help people with disabilities live, work and play in the community.  ·         Changes to Medicaid should not be made to pay for unrelated health care reform efforts. ·         Congress should work in a bipartisan fashion to improve the Affordable Care Act to achieve comprehensive, accessible and affordable health care and long term services and supports for people with disabilities. Additional Resources: State Fact Sheets: http://www.kff.org/interactive/medicaid-state-fact-sheets/ Center on Policy Priorities analysis: http://www.cbpp.org/research/health/tracking-reports-about-the-emerging-senate-bill-to-repeal-the-affordable-care-act Center analysis of the Medicaid provisions: http://www.cbpp.org/health/commentary-once-passed-medicaid-cuts-wont-be-easily-reversed Visit AUCD’s Action Center to find out the name of your US Senators.

The Medicaid Cap: “Carving Out” Medically Complex Kids Won’t Protect Them

The Senate Leadership is reportedly including a cap on federal Medicaid payments to states in its version of legislation to “repeal and replace” the ACA.  That cap will apparently look a lot like the cap that narrowly passed the House in early May, but with some tweaks to accommodate concerns of individual Senators.

One tweak under consideration has to do with “carving out” medically complex children from the cap. Because no bill text is available, it’s not possible to know for sure how the bill would define medically complex children or how they would be “carved out.”

That said, two points are clear. First, like all of the other 37 million children enrolled in Medicaid, medically complex children need to be protected from the loss of federal funds for needed care. Second, the only way to protect them is not to cap federal Medicaid payments to states for any population—children and families, seniors, persons with disabilities, or pregnant women. Here’s why carving out medically fragile children will not protect them.

Let’s start with the basics of a cap.

The way federal-state matching works in Medicaid is that the state must spend its own funds before the federal government pays its share of the state’s cost. If the state spending is for a covered service furnished to an eligible individual by a qualified provider, the federal government will match the spending at the state’s statutory matching rate on an open-ended basis. The cap on federal Medicaid spending in the House bill would limit the total amount the federal government would pay to a state each year beginning in 2020 and thereafter, in perpetuity, even if the state’s cost is otherwise eligible for federal matching.

As we’ve said before, the fundamental problem with the cap is that it limits federal payments to states but it doesn’t limit the drivers of state Medicaid spending, such things as rapid increases in the price of prescription drugs or increased need for services due to, say, the opioid epidemic.

All costs above the amount of the cap are entirely paid for by the state. In short, the cap is a cost shift from the federal government to the states. States can respond either by paying those additional costs with their own funds or by reducing their Medicaid spending below the level of the cap through cutting payments to providers, eliminating coverage of optional services and optional eligibility groups, and/or restricting the use of services.

Because the cuts in federal Medicaid funds in the House bill are so large, states will find it extremely difficult, if not impossible, to make up the shortfalls with their own funds. The Urban Institute recently estimated that to make up the shortfall without reducing enrollment, states would have to increase their own spending by $370 billion, or 13 percent over the next 10 years. (Reportedly the reductions in the Senate Leadership bill may be even larger).

In the states that decide not to make up the shortfall with their own dollars or those that are unable to do so—which will likely be most states—the focus will be on keeping Medicaid spending below the cap by limiting state spending. Cuts in provider payments, elimination of “optional” services, and restrictions on enrollment of “optional” eligibility groups will likely be among the ways that states try to “manage to the cap.”

If the cap is “dialed down” over time to achieve additional federal budget savings, the challenge for states to keep their spending under the cap will be exacerbated, and the search for additional Medicaid savings will intensify.

In these circumstances, whether medically complex kids are “carved out” from the cap will be largely irrelevant. The operational focus will be on ensuring that payments to providers and utilization of services by all populations are constrained as much as necessary to keep total program spending under the cap—not on exempting these kids from payment or service cutbacks.

Even as the states look for ways to reduce their spending to stay under the cap, the shortfall in federal funding relative to need will increase, especially if the federal government “dials down” the cap.

As the shortfall increases, demand will grow for state funds to replace the federal funds lost to the state budget. The Medicaid program will have to compete with other state programs for limited state funds, and within Medicaid, “carved out” medically complex children will have to compete with other needy populations for state Medicaid funds.

If the state is unable to free up the resources to spend on services for the “carved out” children, the federal government will not make matching payments. In short, a “carve out” for medically complex children does not protect them from the limits on state funds. And without that protection, a “carve out” from the federal cap is meaningless.

As the Center on Budget and Policy Priorities has explained, no population can be protected by a “carve out” – not medically complex kids, not all kids, not parents, not people with disabilities, not seniors.

A “carve out” for medically complex children will make the Medicaid cap appear less “mean.” But it won’t actually protect them or the providers who serve them.

June 21, 2017 Andy Schneider

originally posted here: https://ccf.georgetown.edu/2017/06/21/the-medicaid-cap-carving-out-medically-complex-kids-wont-protect-them/

Action Alert: Contact Your Senator

from National Family Voices:

The Senate released its version of the health care bill this morning. Family Voices Policy staff has taken a first look.  A few notes:

·         This bill has no winners and puts at risk coverage and care for children and youth who have special health care needs, whether they get their insurance through the ACA marketplace, an employer, or through  Medicaid.

·         The “carve out” for blind and disabled children does not help.  It would apply only to a small number of children with special health care needs until they turn 19, and will not even protect them for the effects of the drastic cuts in Medicaid funding.

In short kids and families are losers in this bill.  Call your Senators offices NOW.

(1)   Urge them to oppose the Senate version of the American Health Care Act. As a parent/relative/provider of a child with special health care needs, you appreciate the effort to protect some of these children, but the carve-out for blind and disabled children does not provide true protection for children and youth with special health care needs.  It is for a very narrow group of children, their special needs won’t go away when they turn 19, and even they can’t be protected from the harms of the drastic cuts due to the Medicaid caps.

(2)   Tell your family’s story: Tell them that the bill threatens critical protections and services for your child and family – protections from annual and lifetime coverage limits and unaffordable out-of-pocket expenses, and coverage of essential health benefits and services, such as Katie Beckett waiver/option coverage, home and community-based care waiver services, and Medicaid coverage for general and specialized health care. Tell them what will happen if your child and family lose these protections and services.

Here’s how to reach your Senators:

·         If you know your Senators’ names, call 202‑224‑3121 (not toll free) and ask to be connected to their office(s).

·         OR, use the toll-free numbers below to be connected you with a Republican Senator or House Member from your state. (All Democrats are expected to oppose the health care bill.)

o   English: 866-426-2631

o   Spanish: 877-736-7831 

·         Call, post, tweet, email: Enter your zip code at www.contactingCongress.org to find your Senators’ names, DC and local phone numbers, and their email, Facebook, Twitter, and other social media contact information. Call the DC office first and a local office if you have time.

If you can’t get through by phone or you have time to do more --

·         Email: Send an email (pre-written but should be personalized) to both Senators at once at http://action.communitycatalyst.org/p/dia/action3/common/public/index.sjs?action_KEY=21058. 
 

·         Fax:  Send a free fax to both your Senators at once at 
https://faxzero.com/fax_senate.php.

Tell your Senators they must #ProtectMedicaid and #KeepKidsCovered. 

Get all your friends and relatives and your child’s teachers and health care providers to call too!

Health Care Legislation Update

from National Family Voices:

Health Care Legislation - Update

As reported in the May 10 Washington Update, the House approved the American Health Care Act (AHCA, H.R. 1628) on May 4 with only Republican votes. In addition to replacing significant parts of the Affordable Care Act (ACA), that bill would fundamentally restructure and cut the Medicaid program. (See the May 10 Update and the list of articles and resources below.)

Status of Bill. Although Senate Republican leaders have indicated that they would like to hold a vote on their version of the AHCA by the end of June, just before a congressional recess for Independence Day, it remains unclear whether that will happen. Since no Democrats are expected to support the bill, at least 50 of the 52 Republican Senators will have to support it to secure passage. (Vice-President Pence can cast a tie-breaking vote.) Yet several Senators have been expressing concern about the legislation, in part because many of them have not yet been allowed to see it. See Lisa Murkowski, a crucial Senate swing vote, is very frustrated with AHCA (Vox.com, June 15, 2017).

Due to feedback from governors, health care providers, and other constituents, more Senators are expressing doubts about the Medicaid caps and the loss of consumer protections that would result from the House bill. A bipartisan groups of governors - from Pennsylvania, Ohio, Montana, Nevada, Colorado, Massachusetts, and Louisiana - sent a letter to the Senate Majority and Minority Leaders opposing the House version of the AHCA (S. 1628) - particularly its Medicaid provisions - and urging the Senate to follow principles set out in their letter when crafting its version of the legislation. See Governors from both parties slam House healthcare bill, call for bipartisan Senate approach. Another challenge arose for Senate Republicans when President Trumpreportedly labeled the House bill as "mean."

Yet, rumors suggest that compromises on some of the major issues are getting worked out, as described below, so it is still possible that Majority Leader Mitch McConnell (R-KY) will be able to achieve Senate passage of the bill by the end of next week.

Medicaid Expansion. Within two years, the House bill would eliminate enhanced matching funds for states to expand Medicaid eligibility to childless adults. A group of Senators whose states have expanded the program, led by Senator Portman (R-OH), have proposed a seven-year phase-out period. Observers are predicting that the Senate bill will include a compromise five-year phase out. This may appease the Senators from "expansion states," but make the bill less palatable to some of the Senators who would like to end the expansion more quickly (e.g., Mike Lee of UT and Rand Paul of KY).

Medicaid Caps - Base Year. More Senators are now focused on the fact that their states - those that did not expand Medicaid and/or have historically low Medicaid spending rates - will end up with less federal funding over the years than other states, since they had relatively low spending in the proposed base year (2016). Rumors indicate that the Senate bill will address this problem by giving states some leeway in determining the time period on which the caps will be based.

Medicaid Caps - Inflation Adjustment. Some Senators are concerned about the severity of the Medicaid cuts that will result from capping federal payments to states. Rumors indicate that a compromise has been developed that may satisfy both ends of the political spectrum: the inflation adjustment may be more generous than the one in the House bill until 2025, but then be made harsher as of 2025. Although some lawmakers may assert that the less generous inflation adjustment can be changed before it goes into effect, it is unlikely this will take place, since changing the law will require Congress to "pay for" any increase in the adjustment either by raising taxes or cutting spending elsewhere in the budget.

Waivers of Essential Health Benefits and Community Rating. The House bill would allow the Department of Health and Human Services to let states waive the ACA's ten Essential Health Benefits (EHBs), and instead establish their own benefit requirements. States would also be allowed to waive the ACA's requirement that individuals not be charged more for insurance because they have a pre-existing condition ("community-rating"). As a result of these changes, it may be very difficult for consumers to find affordable plans that meet their health needs. Moreover, because the prohibition on annual and lifetime coverage limits and the limits on out-of-pocket spending are applicable only to Essential Health Benefits, these protections could be greatly weakened under the House bill.

 

It has been reported that the Senate bill will allow states to waive EHBs but not community rating. This could still have the effect of increasing premiums for people with pre-existing conditions because they would need plans that cover more services and thus would be more expensive. See If Senate Republican Health Bill Weakens Essential Health Benefits Standards, It Would Harm People with Pre-Existing Conditions (Center for Budget and Policy Priorities, June 12). Allowing states to reduce required benefits would also allow employers to offer insurance plans in which fewer benefits would be subject to protections against annual and lifetime caps and unlimited out-of-pocket expenses. See New changes to essential benefits in GOP health bill could jeopardize protections against catastrophic costs, even for people with job-based coverage, and Allowing states to define "essential health benefits" could weaken ACA protections against catastrophic costs for people with employer coverage nationwide.

 

Reproductive Health. Senators Lisa Murkowski (R-AK) and Susan Collins (R-ME) have expressed strong reservations about the House-bill provision prohibiting Medicaid reimbursement to Planned Parenthood clinics for one year, which would create financial hardship for many of the clinics. On the other hand, some Senators have indicated that they would object to dropping the House-bill provision prohibiting the use of premium tax credits to purchase any health care plan that covers abortion (except for pregnancies resulting from rape or incest or that threaten the life of the mother). The Senate Parliamentarian has warned the leadership that the latter provision might not comport with the rules of reconciliation, so might be subject to a "point of order" that would strike it from the bill.

Advocacy Efforts. Medicaid advocates around the country have been working to educate Senators and their staffs about how AHCA's Medicaid caps would affect states and Medicaid beneficiaries. Advocates have been conveying the message that any form of cap on federal Medicaid spending would be harmful because it changes the nature of the program, shifting costs to states, providers and beneficiaries, and making it easier for Congress to cut Medicaid spending in the future when they need a "pay-for" for other legislation.

Advocates - joined by Democratic and a couple of Republican Senators - have also been criticizing the secrecy surrounding the Senate bill. Even though it may come to the Floor for a vote next week, no one has seen a complete bill, not even most Republican Senators. To make this point, Senate Democratic Leader Chuck Schumer (D-NY) introduced a bill, the "No Hearing, No Vote Act," that would require hearings on major provisions of a reconciliation bill prior to Floor action. See Dems push to require Senate hearing for ObamaCare repeal vote.

Outlook. Despite challenges, it is quite possible that Senator McConnell will figure out a way to get the votes needed to gain Senate passage. He might employ procedural tactics that would result in a vote before Democrats have had a chance to see the bill's language, thus making it difficult for Democrats to argue against it or offer appropriate amendments. In addition, it is possible he will hold the vote before he is certain that the bill will pass, which would put tremendous last-minute pressure on undecided Senators to vote for the bill.

If the bill passes the Senate, then the House could either accept the Senate's bill, or a House-Senate conference committee would be formed to work out a compromise. If both bills contain the Medicaid caps and cuts, then those provisions likely would remain in any final legislation.

For more information about the AHCA and its impact, see -

 

Summaries of AHCA:

• Summary of the American Health Care Act as passed by the House May 4, 2015 (Kaiser Family Foundation)
• Interactive tool from the Kaiser Family Foundation, which provides a side-by-side comparison of current law (ACA) and the AHCA (and other bills).
• Graphic side-by-side comparison of current law (ACA) and the AHCA from the LA Times.

Analyses of AHCA Impact: 

• Restructuring Medicaid in the American Health Care Act: Five Key Considerations (Kaiser Family Foundation, 5/15/17)
• Per Capita Caps Could Reduce Funding for Children Covered by Medicaid: All 50 states and DC would receive fewer Medicaid dollars for non-disabled children.(Avalere, 5/18/17; links to full report)
• At Risk: Medicaid's Child-Focused Benefit Structure Known as EPSDT (Georgetown Center on Children and Families, June 2017)
• Factors Affecting States' Ability to Respond to Federal Medicaid Cuts and Caps: Which States Are Most At Risk? (Kaiser Family Foundation, June 9)
• What's Really at Stake in the Medicaid Spending Debate, from Drew Altman, President and CEO, Kaiser Family Foundation (June 2)
• Impact of Per Capita Caps on Home and Community-Based Services (Center on Budget and Policy Priorities, 5/18/17) (includes state-specific information on the number of people receiving Medicaid home and community-based care) 

For more summaries and analyses of the AHCA and related materials, see the May 10 Washington Update.