There are many opinions circulating this week about the alternative to the Affordable Care Act that the Republican-controlled House of Representatives passed on a 217-213 vote. Rather than hastily cobble together an analysis of our own, we have gathered the official statements of several national organizations that will be most affected in the unlikely event the House bill passes unchanged through the Senate. [Rowan compiles the views on the American Health Care Act of representatives of many national healthcare organizations, including the National Association for Home Care and Hospice; the Visiting Nurse Associations of America; AARP; America’s Essential Hospitals; American Medical Association; American Nurses Association; and Joe Baker, President of the Medicare Rights Center.
National Association for Home Care and Hospice
March 8, 2017
The Republican majority in the U.S. House of Representatives released their official Affordable Care Act (ACA) repeal and replace legislation, the American Health Care Act (AHCA) and on first glance it appears to be a mixed bag for home health and hospice.
The new legislation will be marked up by two different committees — Ways and Means and Energy and Commerce on Wednesday morning. Controversially, the AHCA has not been scored by the Congressional Budget Office (CBO) yet, meaning legislators do not know how many people this measure will cover, how much it will cost, or the impact it will have on the Medicare Hospital Insurance Trust Fund, better known as Medicare Part A. Below we outline, the good, the bad, and the yet-to-be determined pieces of the American Health Care Act.
Of immediate concern to the Home Care and Hospice community is the repeal of a six percent incentive payment for Home and Community Based Services (HCBS) under the Medicaid program. Simply put, this rebalances the ratio of federal to state responsibility for Medicaid HCBS with the federal government picking up an additional 6%. The intent of this bonus was to drive states to encourage rebalancing of care from institutional settings to home and community environments. This incentive was made available under the ACA. Since its enactment eight states have taken advantage; California, Connecticut, Maryland, Montana, New York, Oregon, Texas, and Washington. An additional five states, Alaska, Arkansas, Colorado, Minnesota, and Wisconsin have applied or are considering accepting the bonus payment.
Of benefit to home health agencies (HHAs) is the repeal of the employer mandate to provide health insurance to employees. This will be accomplished by reducing the penalty for non-compliance to zero. The legislative language is written so as to provide retroactive effect from the mandate. The entirety of calendar year 2016 will be exempted from the mandate. The National Association for Home Care and Hospice (NAHC) has long disagreed with the employer mandate as the added expense to HHAs goes uncompensated by Medicare and Medicaid payments. In private pay situations, the added expense can make home care unaffordable in some cases, pushing patients towards Medicaid institutional care settings instead.
As expected, House Republican leadership included a provision to cap the federal share of Medicaid. They seek to achieve this through “Per Capita Caps.” As we’ve written before, this model provides a predetermined amount of funding allowable to each individual eligible for Medicaid in a given state. The amount will be based on 2016 figures and will be adjusted yearly according to the Consumer Price Index for Medical costs (CPI-Medical). This is expected to result in reduced federal share of Medicaid funding. In turn, states will take on the additional responsibility, and will then be forced to either find alternative revenue sources or limit benefits made available. NAHC is concerned that home care and hospice services as a benefit could be lost in this model.
Due to the added flexibility Per Capita Caps entail, states may favor or disfavor home care services. Each state would have the freedom to define what is and is not covered under Medicaid, and the parameters around program operations. This would potentially include beneficiary cost-sharing responsibility. Further, states could be handicapped in expanding home care options, as rates are tied to 2016 funding figures. However, with the caps, states may find a need to be more efficient in their spending. This could lead to support for home care as a more cost effective solution to nursing home care and as a way to transition patients out of inpatient care with reduced risk on re-admission.
Other notable changes include:
- Increased age-rating ratio. Under the ACA, insurance plans could not charge older persons more than 3 times that of a younger person. A 3:1 ratio. The AHCA would increase that to a 5:1 ratio.
- Repeals the individual mandate under the ACA. In place of this, Insurance companies will be allowed to charge an additional 30% to beneficiaries that had a lapse in coverage greater than 63 days. This extra 30% would be allowable for up to one year.
- In place of subsidies, the AHCA will provide refundable tax credits based on age and income to those who do not receive insurance coverage from their employer.
- Under this legislation, Medicaid Expansion will be rolled back by 2020.
This is only an early look at a large piece of legislation that will affect millions of Americans nationwide. NAHC will continue to review, study, and analyze the impact the AHCA could have on the home care and hospice industry. As always we will keep you up to date with notable events and developments related to health care reform.
Visiting Nurse Associations of America
The U.S. House of Representatives approved the American Health Care Act (AHCA) today by a vote of 217 to 213. Last minute amendments to the bill persuaded enough members of the House Freedom Caucus (a collective of conservative members of the Republican Party) and House Tuesday Group (a collective of more moderate Republicans) to vote in favor of the legislation.
These passed amendments that are now part of the AHCA are:
The McSally Amendment:
Representative Martha McSally (R-AZ) introduced an amendment that would eliminate the exemption from Congressional members and their staffs from provisions within the American Health Care Act.
The Upton Amendment:
Representative Fred Upton (R-MI) introduced an amendment targeting $8 billion from 2018-2023 to help subsidize the insurance costs of individuals with pre-existing conditions. Organizations such as Consumers Union, the Kaiser Family Foundation, and the American Medical Association all agree that $8 billion is insufficient to cover this need.
In late April, the MacArthur Amendment was released to update parts of the AHCA and bridge the gap between conservative and moderate Republicans.
The MacArthur Amendment:
reinstates essential health benefits (EHBs) as the federal standard;
- maintains the prohibition on denying coverage due to preexisting medical conditions and discrimination based on gender;
- guarantees the issue of coverage to all applicants and renewability of coverage;
- allows for coverage of dependents on parents’ plan up to age 26; and
- maintains Community Rating Rules,
- provides an optional waiver for states to bypass the EHB standard and certain Community Rating Rules.
As VNAA previously alerted members, the AHCA would repeal key portions of the Affordable Care Act and make dramatic changes to the Medicaid program. Please note, the legislation does not repeal either the home health payment rate rebasing or the face to face certification requirement. VNAA has carefully monitored this debate to ensure continued accessibility and affordability of home-based care. VNAA remains concerned that AHCA takes a step backwards for vulnerable and home-based care patients. VNAA opposes further passage of the AHCA.
VNAA will continue to monitor and engage in this debate. This House-approved legislation faces considerable challenges in the Senate, setting up negotiations to develop a compromise bill to pass both chambers. As always, VNAA’s goal is to ensure access and affordability to high-quality home care.
AARP
The American Health Care Act (AHCA) would permit discrimination against people with preexisting health conditions, substantially increase insurance premiums for older adults, result in millions of people losing coverage, and worsen the fiscal health of Medicare.
The bill would also cut Medicaid funding, which millions of low-income seniors as well as children and adults with disabilities rely on, by more than $800 billion over 10 years.
The AHCA has been condemned by leading consumer and health groups, including AARP and physician and hospital organizations.
“AARP is deeply disappointed in today’s vote by the House to pass this deeply flawed health bill,” said AARP Executive Vice President Nancy LeaMond. “The bill will put an age tax on us, harming millions of American families with health insurance, forcing many to lose coverage or pay thousands of dollars more for health care. In addition, the bill now puts at risk the 25 million older adults with preexisting conditions, such as cancer and diabetes, who would likely find health care unaffordable or unavailable to them.”
Pulled from House consideration in March when it lacked sufficient votes for passage, the legislation found new life through an amendment permitting states to request waivers that would allow insurers to charge higher premiums to people with preexisting conditions. That would be a dramatic departure from the protections of current law. Twenty-five million people ages 50-64 have a preexisting condition and would face much higher premiums — thousands of dollars a year — that in many cases would be unaffordable.
While supporters of the bill maintained that people with preexisting conditions could be cared for through high-risk pools, an analysis by AARP’s Public Policy Institute found that premiums in such pools could reach unaffordable levels — as much as $25,700 a year in 2019. In the past, high-risk pools have put such an onerous financial burden on states that insurance benefits were scaled back and enrollment in them was capped.
To win over holdouts on the bill, the House leadership included an amendment adding $8 billion over five years for high-risk pools, an amount representing a very small fraction of what would be required.
Under the bill, states could also obtain waivers allowing insurers to sidestep coverage for critical benefits such as emergency services, hospitalization, prescription drug coverage, mental health services, chronic disease management and preventive care.
The controversy over how to treat people with preexisting conditions was only one objection raised by consumer groups about the AHCA. The bill would impose an “age tax” through the combined effect of allowing insurers to charge older adults five times what other consumers pay for the same insurance and reducing tax credits that help older adults pay for their insurance coverage. The result of these two big changes would be an increase in annual premiums of up to $13,000, according to the Congressional Budget Office (CBO).
Compounding this problem, insurers in states receiving a federal waiver would be allowed to charge older adults even more than five times what others pay for coverage. Current law limits the premiums for older consumers to three times what younger adults are charged.
The CBO found in March that the legislation would lead to a loss of coverage for 24 million Americans over the next decade. The House leadership plunged ahead with Thursday’s vote even though the CBO has yet to analyze the recent changes. The result was that members of Congress voted on legislation without knowing how many people would be affected and how much their premiums would be.
The AHCA wouldn’t affect only people 50 to 64 years old. The bill would also worsen the fiscal outlook for Medicare by reducing the program’s revenue. It would hasten Medicare’s insolvency by several years and weaken its ability to pay for future services for those who rely on the program to help cover their health care costs.AARP vowed to hold every member of Congress who voted for the bill accountable by letting its nearly 38 million members know how their elected representatives voted.
America’s Essential Hospitals
Statement on House Passage of the American Health Care Act
Statement attributable to:
Bruce Siegel, MD, MPH
President and CEO
WASHINGTON – The House voted today to take health care coverage away from tens of millions of Americans, reduce benefits and increase costs for millions more – including the sick – and gut a program that has been a lifeline for vulnerable people for more than 50 years.
This is not reform. This is legislation that will take us back to a time when working individuals and families were forced to choose between health care coverage and life’s other necessities. In fact, it will leave us in a worse place than before the law it seeks to replace, the Affordable Care Act.
The hospitals and health systems that care for disadvantaged Americans, essential hospitals, meet their mission across all states and localities – blue and red, urban and rural. But the draconian cuts to Medicaid and soaring levels of uncompensated care this bill would create put that mission in jeopardy. If this bill becomes law, it will put all communities at risk of losing access to basic care and vital services, including trauma care and disaster response.
It is particularly telling that an overwhelming majority of Americans oppose this legislation and no major stakeholder group supports it. The Senate must heed those warning signs and stop this damaging legislation. The solutions we need to fix the shortcomings of the ACA demand a more deliberative process that brings all stakeholders, including our hospitals, to the table.
With a measured approach, we can preserve access to affordable health care and protect struggling Americans from the massive loss of coverage that almost certainly will occur under the AHCA. We offer our members’ experience and expertise to achieve those goals.
About America’s Essential Hospitals
America’s Essential Hospitals is the leading association and champion for hospitals and health systems dedicated to high-quality care for all, including the most vulnerable. Since 1981, America’s Essential Hospitals has initiated, advanced, and preserved programs and policies that help these hospitals ensure access to care. We support members with advocacy, policy development, research, and education.
Our nearly 300 members are vital to their communities, providing primary care through trauma care, disaster response, health professional training, research, public health programs, and other services. They innovate and adapt to lead the broader health care community toward more effective and efficient care.
American Medical Association
President Andrew W. Gurman, M.D., released the following statement today after the U.S. House of Representatives passed the American Health Care Act:
“The bill passed by the House today will result in millions of Americans losing access to quality, affordable health insurance and those with pre-existing health conditions face the possibility of going back to the time when insurers could charge them premiums that made access to coverage out of the question. Action is needed, however, to improve the current health care insurance system. The AMA urges the Senate and the Administration to work with physician, patient, hospital and other provider groups to craft bipartisan solutions so all American families can access affordable and meaningful coverage, while preserving the safety net for vulnerable populations.”
American Nurses Association
“In its current form, the bill changes Medicaid to a per capita cap funding model, eliminates the Prevention and Public Health Fund, restricts millions of women from access to critical health services, and repeals income based subsidies that millions of people rely on. These changes in no way will improve care for the American people,” the organization wrote in a letter March letter.
The group’s president tweeted on Thursday, calling the bill “worse than before.”
Joe Baker, President of the Medicare Rights Center
New York, NY—The American Health Care Act (AHCA) undercuts our core mission and violates our driving principles — to ensure older adults and people with disabilities are assured access to affordable, high-quality health care. This bill was written in the dark of night and rushed to the floor for a vote without anyone knowing how much it will cost or how many people it will affect.
The American people deserve better than Congress playing fast and loose with their health care, but it’s the substance of the AHCA that alarms us most of all. The AHCA would yank coverage out from under 24 million Americans, end Medicaid as we know it, weaken protections for people with pre-existing conditions, impose an unaffordable “age tax” on older Americans, and undermine the Medicare guarantee. The AHCA puts access to affordable health care at risk for every older adult, person with a disability, and American family, especially as our society ages and becomes increasingly reliant on Medicare and Medicaid.
We are undaunted by today’s vote, and we will continue to fight the AHCA’s passage. We ask the U.S. Senate to start from scratch and to seek consensus on health care reforms that protect and strengthen affordable access to care for American families, and we urge President Trump keep his campaign promise not to cut Medicare and Medicaid.
For more information on the Medicare program and proposals under consideration by Congress to change it, visit the Medicare Rights Center’s “Protect and Strengthen” webpage at medicarerights.org/protect.
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