What Went Down On Health Care This Week

One thing worth bearing in mind throughout the next crazy hours of Senate debate: Senate Majority Leader Mitch McConnell chose to approach the GOP effort to repeal and replace parts of the ACA using the reconciliation process. The benefit of this process for the GOP is that it needs only 50 votes to pass — with Vice President Mike Pence as tiebreaker — so the party doesn’t have to work with Democrats to craft or pass the bill. The down side is that there are limitations on what can be included in the bill, because each provisions must be primarily about making changes to the budget. It also puts a deadline on passing the bill for complicated reasons. The Senate parliamentarian, who determines whether the bill follows those rules, has issued guidance that many of the GOP ideas included in the various iterations of Senate legislation proposed so far don’t comply. That includes provisions that would:

• Restrict funding for Planned Parenthood.
• Allow insurers to charge older adults five times as much as younger adults.
• Institute a six-month waiting period to buy insurance if you haven’t had continuous coverage (which is supposed to function as a replacement for the individual mandate).
• Make available waivers to allow states to forgo insurance market regulations.

Getting rid of these provisions makes Swiss cheese out of the bills Republicans have put forward so far. It’s unclear what that will mean for their final bill proposal. At the moment, two of the options seem to be to leave those provisions out (as would be the case with a true “skinny repeal” bill that just ended the individual mandate, the employer mandate and perhaps a few other things) and hope they can get enough votes without them, or they could choose to overrule the parliamentarian, ending the Senate as we know it.

One of our live blog commenters asked, “Have any bills died in conference after being passed by both chambers since 1980? Or is passage in both chambers a guarantee of … something?” All of the reconciliation bills listed below — those that went to conference committee after being passed in some form by both chambers — were subsequently approved by both chambers, after coming out of the conference committee. Not all of them became law — a few were vetoed by the president — but the vast majority did. Still, successful passage in the past doesn’t mean that the same thing will happen this year, with potentially major differences between the two chambers’ bills.

Reconciliation bills that went to conference committee

FISCAL YEAR	BILL	BECAME LAW
1981	Omnibus Reconciliation Act of 1980	✓
1982	Omnibus Budget Reconciliation Act of 1981	✓
1983	Tax Equity and Fiscal Responsibility Act of 1982	✓
1983	Omnibus Budget Reconciliation Act of 1982	✓
1986	Consolidated Omnibus Budget Reconciliation Act of 1985	✓
1987	Omnibus Budget Reconciliation Act of 1986	✓
1988	Omnibus Budget Reconciliation Act of 1987	✓
1990	Omnibus Budget Reconciliation Act of 1989	✓
1991	Omnibus Budget Reconciliation Act of 1990	✓
1994	Omnibus Budget Reconciliation Act of 1993	✓
1996	Balanced Budget Act of 1995
1997	Personal Responsibility and Work Opportunity Reconciliation Act of 1996	✓
1998	Balanced Budget Act of 1997	✓
1998	Taxpayer Relief Act of 1997	✓
2000	Taxpayer Refund and Relief Act of 1999
2001	Marriage Tax Relief Reconciliation Act of 2000
2002	Economic Growth and Tax Relief Reconciliation Act of 2001	✓
2004	Jobs and Growth Tax Relief Reconciliation Act of 2003	✓
2006	Deficit Reduction Act of 2005	✓
2006	Tax Increase Prevention and Reconciliation Act of 2005	✓
2008	College Cost Reduction and Access Act	✓

Few people know more about Medicaid than Andrea Louise Campbell. An expert in American social policy, in 2014, she published “Trapped in America’s Safety Net: One Family’s Struggle,” which tells the story of her sister-in-law, Marcella Wagner. In 2012, a reckless driver forced Wagner into a car accident near her northern California home. She was more than seven months pregnant at the time, and though her son was born without major trauma, the accident left Wagner paralyzed from the chest down. Medicaid — or Medi-Cal, as it is known in California — became the central payer of health care for Wagner and her family. At the same time, its rules came to place powerful limits on Wagner and her family, in effect committing them to a lifetime of poverty. And even though Campbell was already an expert on American social policy, her up-close experiences with Medi-Cal as a result of the accident changed Campbell’s views on the American safety net. Her book uses Wagner’s story to provide key details about how Medicaid does and does not work for the patients who rely on it. I asked her about Medicaid reform generally and the proposals currently being considered. The transcript below has been lightly edited. Dan: Imagine that you were advising Congress about reforming Medicaid. What are the kinds of reforms you’d be encouraging them to consider? Campbell: My preferred reforms would increase eligibility and decrease out-of-pocket costs for Medicaid beneficiaries to include more citizens under the program’s protections and to make it easier for beneficiaries to afford the care they need. First, 19 states have not expanded Medicaid eligibility under the ACA, leaving millions without insurance; I’d love to see those states brought into the fold. Second, although Medicaid recipients in the expansion states who are newly eligible do not face asset limits, about half the states still impose an asset limit on the original eligibility groups, such as the disabled and poor families with children. Such individuals and families are required to have assets below $1,000 or $2,000 or $3,000 to be able to enroll (while the newly eligible under the ACA – such as low-income single adults — do not face such asset caps). That perverse siloing should disappear. Third, a number of states have imposed cost-sharing on Medicaid recipients, such as monthly premiums or copays. Typically such cost-sharing has been sought by conservative states desiring recipients to have “skin in the game.” But studies show that even modest cost-sharing has a negative effect on utilization among the kinds of low-income populations that Medicaid serves. Dan: How do those reforms compare with the Medicaid reforms that have actually been on the table? Campbell: The reforms I just outlined are utterly pie-in-the-sky compared to what’s been on the table in recent months. I seek expansion; the bills on the table severely contract Medicaid. First, the various Republican bills roll back the ACA’s Medicaid expansion. While the federal government pays 50 to 75 percent of Medicaid costs for the original eligibility groups, with poorer states getting the larger match, the ACA enticed states to expand Medicaid to cover all poor people by paying 100 percent for the newly eligible in the short-term, and 90 percent thereafter. The Republican bills eliminate the enhanced federal funding, and most states lack the resources to make up the difference. Millions of people would be eliminated from the Medicaid rolls. Second, and even more fundamentally, the reform bills end Medicaid’s entitlement status. They roll back the federal government’s commitment to Medicaid and increase fiscal risk to the states. Since the program’s inception in 1965, everyone deemed eligible by the states has been entitled to Medicaid services. The federal government has provided as many matching dollars as needed to cover each state’s eligible population. The Republican bills instead impose a per capita payment – a set amount per beneficiary – which uncouples the federal contribution from actual health care spending. Although the reform bills have different per capita payments for different types of beneficiaries (smaller payments for poor children, who are relatively cheap to cover, larger payments for nursing home residents who are much more expensive), the fixed payments nonetheless shift fiscal risk onto states, who can ill afford it. Putting the caps in place makes it easy to reduce federal spending in the future; Congress can simply set the annual adjustment to a rate below medical inflation. Some proposals start the caps at states’ current per capita spending for each Medicaid subgroup; the initial cap would be lower for the non-expansion states, putting them at a disadvantage. And it’s easy to imagine an outbreak of Zika or the huge costs of opioid addiction treatment blowing through those per capita caps, leaving states on the fiscal hook. And that’s why we’re seeing so much opposition to the Congressional reform bills from governors. They realize that they’ll have to cut other state spending – already tight – or raise taxes to make up for the federal shortfall. I’m sure the nation’s 33 Republican governors really appreciate being thrown under the bus by their co-partisans in Congress. And then well beyond the implications of the reform bills for state budgets are the implications for Medicaid recipients and their families. In recent decades, states have received federal waivers to allow them to provide home and community based services – home health care – to the disabled rather than limiting them to nursing home care. If there are large Medicaid cuts, states are going to be forced to decide who to cover. They may need to cut the number of home health care hours available to the disabled and elderly, which are already too limited in many states. This will raise the informal caregiving burden for millions of adult children, who will have to reduce their work hours or quit work altogether. What will happen to the disabled and the elderly without such family members, I simply can’t imagine.