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ACA Round Up - 3/10

By Shalini Pammal
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TAKE ACTION 
  •  Send a letter to the editor of your local paper today about the House Republican ACA repeal bill. Numerous members have already submitted LTEs to papers across the nation. We need everyone to make their voice heard in every state across the country, but it's even more important for those of us who have a Republican House member.

  • Register for the 2017 National Leadership Conference for the opportunity to connect with and learn from fellow advocates across the nation who are organizing for quality, affordable healthcare. 
 
WEEK-AT-A-GLANCE
 
On Monday evening, House Republicans finally unveiled the long-awaited replacement plan for the Affordable Care Act: The American Health Care Act. Following marathon sessions, both the House Ways and Means Committee and the House Energy and Commerce Committee approved the replacement plan yesterday, hastily ushering the bill to a vote without a CBO score, and despite conservative opposition to the plan. The bill passed on a party line vote without significant amendments. Committee chairmen discouraged major changes in the bill, which must still be approved by the House Budget Committee and then the Rules Committee. The bill is expected to go through two more weeks of committee process before heading to the House floor for a vote on March 23 (the 7th anniversary of the ACA). Republicans plan to have the Senate vote and send it to the President's desk by April 7, before the next big recess. In a meeting with representatives from five conservative Republican groups earlier this week, the White House indicated that the bill is still open for negotiation; however, negotiations to formulate a bill acceptable to the entire GOP leadership will be difficult. 
 
President Donald J. Trump envisions the Affordable Care Act repeal-and-replace process progressing in three phases, beginning with reconciliation. The Department of Health and Human Services will then initiate regulatory adjustments and phase three would involve drafting additional legislation to include provisions that are not related to spending or revenue. This bill will most likely change as it goes through the Committee process.
 
Roll-out of the American Health Care Act has been rocky, as the GOP faced opposition from numerous provider groups including the American Hospital Association and the American Medical Association, as well as industry associations, Republican conservative activist groups, health policy experts, and the Democratic coalition. One divisive issue has been the changes to tax credits that Republicans proposed in the bill. The ACA based credits on income, while the ACHA primarily uses age as a metric, phasing out credits for individuals as they age. The AARP has spoken up that this bill creates an "age tax" that makes insurance more expensive for people nearing retirement age. Other groups that would experience increased in out-of-pocket costs would be the poor, and people in rural areas who tend to have higher premiums. ACA tax credits were relative higher in areas with higher premiums (and tied to a baseline costs of plans in a certain area), while the replacement proposal credits do not vary by location. The bill also allows insurers to charge older customers up to five times as much as younger adults. Under ACA regulations, insurers were only allowed to charge three times as much. Medicaid expansion funds are also phased out after 2020 and the bill restructures the program to cap payments. It is estimated that 15M would lose coverage under ACHA due to the cuts in both Medicaid and private insurance expansions. Other estimates predict 10M losing coverage, mainly from Medicaid and the individual market. Larger states like California and New York will be able to keep enrolling people in Medicaid using state-level funds; but, states with smaller tax bases-- like Kentucky or West Virginia-- will have a harder time maintaining enrollment.
 
Conservative organizations such as the Heritage Action Club for Growth are arguing that changes to the Affordable Care Act do not go far enough to undo the law. Tax credits are a major issue for Senator Rand Paul and Senator Mike Lee, as well as other members of the House Freedom Caucus, as they view these provisions as a way to preserve the ACA, creating an "Obamacare Lite." Further, phasing out Medicaid expansion has drawn fire from Republican governors and Republican congressional leadership in states that accepted expansion funds under the ACA.
 
Regarding other provisions, some business groups and industry associations have offered their support. The United States Chamber of Commerce approved of the Cadillac tax delay, the repeal of many ACA-associated taxes, and the exclusion of the cap on tax breaks for employer-sponsored health plans that had been included in an earlier version of the bill. AHIP supports that the bill doesn't touch Medicare or employer-sponsored health plans, but warns Republicans leadership that changes in Medicaid financing could harm coverage and care. Blue Cross Blue Shield Association also believes that proposed financial assistance is too small to promote widespread health coverage. BCBSA warned that the 30% surcharge penalty for breaking the 'continuous coverage' requirement would keep younger, healthier people out of the insurance market. 
  
Underscoring the speed and secrecy with which Republicans are seeking to push this repeal bill through, House Minority Whip Steny Hoyer noted that the ACA had 79 public hearings, versus 0 planned to discuss the AHCA. That means doctors, medical students and health advocates must speak out now and vocally to make our voices heard. President Trump will be in Nashville, Tennessee on Wednesday to sell his plan.
 
ABOUT THE AMERICAN HEALTH CARE ACT
 
Bottom line: Overall, the American Health Care Act will mean fewer insured, weaker protections, and higher costs for many Americans. Some ACA provisions cannot be changed under the budget reconciliation rules that apply to this bill and could be repealed under future bills. Here are some specifics of the AHCA 

What remains in ACHA 

  What has been eliminated in ACHA   New or changed by ACHA
Provision allowing children to stay on parents' insurance plans until 26   Variety of taxes included in the ACA, effective after December 31, 2017: medical device tax; branded prescription drug tax; health insurance tax; tanning tax; 0.9% surcharge tax for high-earners (above $250,000) and 3.8% tax on investments   As a substitute to the individual mandate, allows insurers to charge a one year 30% surcharge on premiums to consumers that do not maintain continuous coverage
Requirement that insurers accept everyone regardless of pre-existing conditions   Enforcement of individual mandate   Continuous coverage penalty kicks in if individual experiences 63 or more continuous days without coverage in a 12-month look back period
40% Cadillac tax on high value plans but implementation is delayed until 2025   Enforcement of employer mandate   Premium rating change for older enrollees - under the ACA, older enrollees could not be required to pay more than 3X the rate of younger enrollees; under ACHA, required to pay more than 5X rate of younger enrollees
Employer tax exclusion for health coverage   Medicaid funding for Planned Parenthood and other organizations that perform abortions   Expanded tax break for health insurers; plans can write off up to $1M of executives' performance-based pay from their tax bill (previously $500,000 write-off)
Prohibition on lifetime and annual dollar limits   Use of tax credits to purchase a health plan that covers abortions   Changes to HSAs and the maximum amount an individual can contribute to his or her HSA ($6,500 for an individual; $13,100 for a family) starting in 2018
Limit on out-of-pocket minimums   ACA-mandated Medicaid DSH cuts, slated to start in FY2018, for non-expansion states eliminated   Re-instates retiree drug deduction for employers recieving Medicare Part D prescription drug subsidy starting in 2018
Required coverage for routine costs of clinical trials   In expansion states, DSH cuts repealed starting in FY2020   Removes ACA prohibition on reimbursement for tax-free OTC drugs starting in 2018
Ban on recissions   Minimum essential benefits requirement in Medicaid expansion plans at the end of 2019   New "high-risk" pool safety net funding of $10 billion pool among non-expansion states from 2018 through 2022
Uniform coverage of emergency room services for in-network and out-of-network visits   ACA subsidy to reduce low-income enrollees' cost-sharing in private health plans, effective at the end of 2019   Gradual phase-out of Medicaid expansion starting in 2020; shifts Medicaid funding from current, open-ended federal matching payments to block grant model in FY2020 (per capita cap subject to income inflation)
Employer reporting regulations   Medicaid: ACA requirements that the benchmark benefit package for Medicaid expansion population be equivalent to the ACA essential health benefits eliminated as of December 31, 2019   Current enrollees can stay in current Medicaid structure until 2020 until they leave program
Requirement to cover 10 essential health benefits (EHBs) including maternity care and preventative services (individual and small group phased out in Medicaid expansion by 2020)       ACA income-based tax creditreplaced by age-based advanceable refundable tax credit program in 2020

Prohibition on waiting periods in excess of 90 days

DOCTORS IN ACTION 

Tell us about what you are up to! Email your updates and photos to DFAHQ@drsforamerica.org

Arizona

Dr. Nicholas Vasquez shares that a group of emergency room doctors when to Capitol Hill to meet with Arizona leaders about the importance of keeping Medicaid expansion. They made it clear that doctors in their state, which expanded Medicaid, are not supportive of block grants.

California

Dr. Jay W. Lee, Chief Medical Officer at the Venice Family Clinic, wrote an op-ed in Medium highlighting the moral reasons for not repealing the ACA.

“Did you know as many as 45,000 preventable deaths are linked to lack of health care coverage every year? Before Obamacare, I remember the heartache of caring for patients who didn’t have health insurance or who had inadequate health coverage. People died early due to lack of access to medications or lack of access to surgeries. When Obamacare finally passed, the chief comment I heard became: “I haven’t seen a doctor in 10 years. I’m so happy to be here today.”

Illinois

First year medical student Jay Dumainian wrote a letter to the editor about cutting Public Health Funds which was published in the Chicago Tribune.

“U.S. House Speaker Paul Ryan and the Republican Party like to paint themselves as the party of fiscal responsibility. But the plan he unfurled on Monday cuts back some core health care initiatives that health care experts of all political walks agree are essential to keeping costs down and Americans healthy. In particular, the Affordable Care Act’s Prevention and Public Health Fund finds no quarter in the GOP plans, which trims the public health fund’s $1 billion budget to a big round number.”

North Carolina

Dr. Seanta Danica Clark joined the Save My Care Bus at stops in Charlotte and Greensboro, North Carolina where speakers discussed how the House Republican plan would mean fewer covered, weaker protections, higher costs and worse coverage.

Pennsylvania

Annie Liu shares that she and other medical students at the University of Pittsburgh are collecting signatures for a letter to PA lawmakers asking them to protect the ACA. They plan to deliver the letters, along with educational materials and patient stories, to city, state, and national lawmakers in Pittsburgh. 

Rhode Island

Jonathan Staloff, a rising third year medical student at Brown University and founder of Brown Medical Students for the ACA shares, that he recently spoke at a ACA rally organized by Rhode Island’s Congressional delegation. Other speakers at the event included Senator Whitehouse, Senator Reed, and Congressman Langevin. You can watch the video here.

Wisconsin

Dr. Dipesh Navsaria penned an op-ed in the CAP Times about the Republican ACA repeal bill. Read more here.

It changes Medicaid to a per capita block grant in 2020. This means a set amount of money is laid out per person to cover the cost of providing Medicaid. While this may not seem like a big problem, this is more or less what is already done in Puerto Rico. In many years, they ran out of money before the fiscal year ended. Then — Zika happened.”

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