Providers’ AHCA wor­ries rise after lat­est CBO anal­y­sis

Modern Healthcare - - NEWS - By Mara Lee and Matthew We­in­stock

The Con­gres­sional Bud­get Of­fice’s lat­est anal­y­sis of the Amer­i­can Health Care Act fur­ther stoked provider con­cerns about the leg­is­la­tion’s po­ten­tial im­pact on ac­cess and cov­er­age and the over­all ef­fect on the health­care in­dus­try.

In its highly an­tic­i­pated scor­ing of the bill, the non­par­ti­san CBO es­ti­mated that 14 mil­lion peo­ple would lose cov­er­age next year, grow­ing to 23 mil­lion by 2026. If those num­bers come to fruition, the to­tal num­ber of unin­sured Americans would hit 51 mil­lion over the next decade. Based on cur­rent pop­u­la­tion growth pro­jec­tions from the U.S. Cen­sus Bureau, that would es­sen­tially re­turn the unin­sured rate for the non-elderly to just be­low pre-Af­ford­able Care Act lev­els, at about 15%. The unin­sured rate hov­ered around 16% for the decade pre­ced­ing ACA im­ple­men­ta­tion, ac­cord­ing to the Kaiser Fam­ily Foun­da­tion.

Most of the an­tic­i­pated cov­er­age de­clines would come from end­ing the fed­eral govern­ment’s en­hanced Med­i­caid match in 2020. In its place, the bill would es­tab­lish a per capita cap based on 2016 spend­ing fig­ures. After that, the cap would be tied to the Con­sumer Price In­dex for med­i­cal care. States that wanted to con­tinue their Med­i­caid ex­pan­sion would be on the hook for mak­ing up the dif­fer­ence. Over­all, fed­eral spend­ing on Med­i­caid would drop by $834 bil­lion by 2026.

It’s hard to know ex­actly how that will play out for pa­tients and providers, but the pic­ture isn’t pretty. Take Ge­or­gia, where com­bined state and fed­eral spend­ing on Med­i­caid is about $4,000 a per­son, rank­ing the state 48th in the coun­try. “There’s a rea­son why we’re 48th, put it that way,” Grady Health Sys­tem CEO John Hau­pert said of the state’s will­ing­ness to spend on med­i­cal care for the poor. “You would have to look at ev­ery chan­nel Med­i­caid flows through. Long-term care. Out­pa­tient—what will be

cov­ered? What won’t? It has to come from some­where.”

The CBO also found that the AHCA would re­duce the fed­eral deficit by $119 bil­lion by 2026, $32 bil­lion less than an ear­lier ver­sion of the bill.

The sav­ings—crit­i­cal to the Repub­li­cans’ strat­egy to pass the bill in the Se­nate through bud­get rec­on­cil­i­a­tion—are lower be­cause states seek­ing waivers to change their in­sur­ance pro­grams would re­ceive some fund­ing to help cus­tomers who would be faced with higher costs. The waivers would al­low states to free in­sur­ers up from cov­er­ing 10 es­sen­tial ben­e­fits man­dated by the ACA.

The re­port out­lined three sce­nar­ios that states would be likely to fol­low:

Don’t ap­ply for waivers re­gard­ing es­sen­tial ben­e­fits and com­mu­nity rat­ing.

Ap­ply for waivers, but don’t al­low in­sur­ers to charge sick peo­ple if their cov­er­age lapses.

Ap­ply for waivers and re­turn to med­i­cal un­der­writ­ing.

Pre­mi­ums would fall 10% to 30% in the sec­ond group, but those sav­ings would come from drop­ping es­sen­tial ben­e­fits cov­er­age. Peo­ple with pre-ex­ist­ing con­di­tions would no longer be pro­tected, some­thing Repub­li­cans promised would not hap­pen.

In the third group of states, “peo­ple who are less healthy (in­clud­ing those with pre-ex­ist­ing or newly ac­quired med­i­cal con­di­tions) would ul­ti­mately be un­able to pur­chase com­pre­hen­sive non­group health in­sur­ance at pre­mi­ums com­pa­ra­ble to those un­der cur­rent law, if they could pur­chase it at all,” the re­port said. “As a re­sult, the non­group mar­kets in those states would be­come un­sta­ble for peo­ple with higher-than-av­er­age ex­pected health care costs.”

Any fund­ing set aside for high-risk pools would not be enough to cover the es­ti­mated 1 in 6 peo­ple who would live in states in the third group.

Dr. Nick Turkal, CEO of Aurora Health Care, a 15-hos­pi­tal sys­tem based in Mil­wau­kee, is con­cerned the loss of cov­er­age would drive pa­tients to the emer­gency depart­ment rather than get­ting the care in pre­ven­tive and pri­mary-care ser­vices.

“That’s not an ef­fi­cient way of get­ting care,” he said.

Si­mul­ta­ne­ous to re­lease of the CBO re­port, the non­par­ti­san Joint Com­mit­tee on Tax­a­tion is­sued its as­sess­ment of the bill’s im­pact on fed­eral rev­enue. The AHCA’s re­peal or de­lay of many tax­ing pro­grams in the ACA would slash fed­eral rev­enue by $662.6 bil­lion from 2017 through 2026, the com­mit­tee found.

The two re­ports did lit­tle to el­e­vate the stature of the House bill, which is al­ready facing an up­hill bat­tle in the Sen- ate. Sen. La­mar Alexan­der (R-Tenn.), chair­man of the Health, Ed­u­ca­tion, La­bor and Pen­sions Com­mit­tee, in a state­ment re­it­er­ated that the Se­nate is com­mit­ted to writ­ing its own bill. In a speech on the Se­nate floor, Fi­nance Com­mit­tee Chair­man Orin Hatch (R-Utah) said law­mak­ers need to be “re­al­is­tic about the lim­i­ta­tions” of what can be achieved and “be will­ing to prac­tice the art of the doable.”


House Speaker Paul Ryan won AHCA pas­sage without a CBO score.

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