posted on Tuesday, June 20, 2017
By John Sawyer, NACHC
Senate leaders, led by Majority Leader Mitch McConnell (R-KY),
have set an ambitious timeline for consideration of that chamber's
version of health care legislation, after the House passed its
version on May 4th. On June 30th, Congress leaves for a
week-long recess and the July 4th holiday, and Leader McConnell's
goal is to pass a bill before that break. Water cooler conversation
around D.C. health policy circles is nearly all focused on whether
they can meet that mark.
With tight deadlines in place and a very tight margin for error
(the GOP majority can only afford to lose two of its members,
should all Democrats vote no) Senate leaders have been playing a
game of three-dimensional chess to fashion a bill that can pass the
chamber. While the process has proceeded largely out of public view
(something for which leaders have been criticized), a broad sense
of the direction and the major sticking points is starting to
emerge. Based on what we're hearing, the following issues are still
- Medicaid. Much more so than in the
House, Senators have waded deep into the weeds of Medicaid reforms.
Senators representing states which expanded Medicaid under the ACA
have expressed concern about the House's rollback of the expansion,
though by and large appear to be advocating for a slower "phase
out" of the expansion funds, rather than for keeping it altogether.
Discussions have ranged from a three-year to a seven-year so-called
"glide path" for lowering federal funding for the expansion. More
conservative Senators are arguing that the growth rate in the
Medicaid "per-capita cap" included in the House bill was too
generous, and that more money could be saved by lowering that rate.
Debates are ongoing about if any additional areas should be "carved
out" from states' calculations of the cap, as well as how the "base
year" (or the starting point for cap calculations) should be
- Tax Credits. The House bill would
replace the ACA system of income-based subsidies for the purchase
of private insurance with a new tax credit system based instead on
a beneficiary's age. However, the
Congressional Budget Office analysis of the House bill
found that it would be difficult for these tax credits to cover the
cost of care - the CBO estimates the credits would
be particularly insufficient for low-income, rural, elderly
patients. Multiple Senators have focused their efforts on making
the tax credits more generous, especially for this particularly
vulnerable group of patients.
- Taxes. Both categories of changes
outlined above, for the most part, are costly to change, especially
if Senate leaders aim to appease more moderate members by making
the bill more generous. Because Senate rules dictate that the
Senate's bill cannot spend more (or in this case, save less) than
the House bill, Senators will need to find a way to pay for these
changes. The main avenue discussed has been to change the House
provisions when it comes to repealing taxes instituted by the ACA.
Some of these tax cuts could come out of the bill altogether, and
some could be "pushed out" to take effect further into the future.
However, conservative Senators (and now
some House members too) are weighing in with concerns
about anything less than full repeal of the ACA taxes.
- Insurance Regulations. After collapsing
in March due to a lack of support, the effort to pass the House
health care bill was revived by several amendments. One of these,
MacArthur amendment, allowed states to waive certain consumer
protections put in place by the ACA, including the prohibition on
plans charging sick patients more, and the "essential health
benefits" plans are required to cover. Questions remain over
whether the MacArthur amendment would be permissible under Senate
procedural rules, which require that all provisions of the bill be
budget-related, not policy-related.
These are by no means the only issues on the table, but
represent some of the big categories shaping the tightrope Senate
leaders must walk to pass a bill. NACHC has
expressed our concern with several aspects of the
House-passed legislation, in particular those provisions related to
Medicaid, and the effect these changes would have on health centers
and those we serve. Working in tandem with state and regional
primary care associations, health centers, and other national
partners, we continue to engage with all parties in the Senate to
improve the legislation. You can take action too - click here to weigh in with your
Senators at this critical moment.