Af­ter an­other ACA re­peal at­tempt fails, the GOP faces tough choices

Bi­par­ti­san ef­forts to sta­bi­lize the in­di­vid­ual mar­ket, which also sought to give states in­creased flex­i­bil­ity in their Med­i­caid pro­grams, were thwarted when Se­nate Ma­jor­ity Leader Mitch McCon­nell made Gra­ham-Cas­sidy a pri­or­ity.

Modern Healthcare - - NEWS - By Vir­gil Dick­son

As some mourn and oth­ers cheer the demise of the Gra­ham-Cas­sidy bill, which aimed to re­peal and re­place the Af­ford­able Care Act, there is lit­tle doubt in any­one’s mind that Repub­li­cans will con­tinue their push for con­ser­va­tive health­care re­form.

“It’s like a zom­bie that won’t stay in the ground,” said John Gor­man, a for­mer CMS of­fi­cial who now con­sults with gov­ern­ment-spon­sored health plans.

The GOP’s de­ter­mi­na­tion stems from seven years of cam­paign­ing and promis­ing con­stituents that they’d do away with Oba­macare. But ques­tions re­main on what—and when—they’ll try again.

One thing is clear: Chances are slim that Repub­li­cans can go it alone any­time soon. A pro­ce­dural route that al­lowed them to pass a re­peal-and-re­place bill in the Se­nate with a sim­ple ma­jor­ity ex­pired Sept. 30. That means an­other at­tempt to mod­ify the ACA would need Demo­cratic sup­port. Per­haps as a threat to his own party, Pres­i­dent Don­ald Trump last week said he’s will­ing to ne­go­ti­ate with Democrats on a bi­par­ti­san bill, with the hope of iron­ing some­thing out by early next year.

More im­me­di­ately, law­mak­ers are likely to re­visit a bi­par­ti­san ef­fort fronted by Sens. La­mar Alexan­der (R-Tenn.) and Patty Mur­ray (D-Wash.) to sta­bi­lize the in­di­vid­ual mar­ket in 2018, ac­cord­ing to Evan Siegfried, a GOP strate­gist. Those ef­forts, which also sought to give states in­creased flex­i­bil­ity in their Med­i­caid pro­grams, were thwarted when Se­nate Ma­jor­ity Leader Mitch McCon­nell made Gra­ham-Cas­sidy a pri­or­ity.

There is true con­cern on both sides that with­out a leg­isla­tive fix, pre­mi­ums could end up be­ing too high for con­sumers or they may find them­selves with few or no in­sur­ance choices. Nonethe­less, par­ti­san pos­tur­ing could sink this ef­fort, too.

“Democrats, in a po­lit­i­cal sense, have no in­cen­tive to work with Repub­li­cans,” Siegfried said. “They want to wait un­til they are in the ma­jor­ity.”

Not so, said Jon Rein­ish, se­nior vice pres­i­dent with Demo­cratic com­mu­ni­ca­tions firm SKDKnicker­bocker. The party has been stead­fast in its com­mit­ment to en­sure ac­cess to af­ford­able health­care. “Democrats have made it clear from day one that their first pri­or­ity is to strengthen the ex­changes and sta­bi­lize the in­di­vid­ual mar­kets, bring costs down and in­crease choice,” he said. “I don’t see (the party) hold­ing back from pur­su­ing bi­par­ti­san so­lu­tions in the name of deny­ing a win to Repub­li­cans.” Af­ter last week’s spe­cial elec­tion in Alabama though, Democrats may be ask­ing if the po­lit­i­cal will to work to­gether ex­ists on the Repub­li­can side.

The GOP re­ceived a prover­bial warn­ing shot when so- called es­tab­lish­ment can­di­date Sen. Luther Strange lost a GOP pri­mary runoff to Roy Moore, an arch­con­ser­va­tive who had the back­ing of for­mer se­nior Trump ad­viser Steve Ban­non.

“Their base wants (the ACA) to be re­pealed, con­se­quences be damned,” said Demo­cratic strate­gist Craig Varoga. “This self-de­struc­tive be­hav­ior will only be ex­ac­er­bated by Roy Moore’s win in Alabama, which will pro­voke panic among main­stream Repub­li­cans who might face right-wing chal­lengers in pri­maries next year.”

GOP in­sid­ers agree. The base is frus­trated that, de­spite con­trol­ling Congress and the White House, re­peal­ing the ACA has re­mained elu­sive. “The frus­tra­tion is McCon­nell and Congress can’t get this done, so we’ll find peo­ple who can,” said Chris Sin­clair, a Repub­li­can strate­gist.

The chal­lenge, how­ever, is that the agenda is now shift­ing to tax re­form, which the pres­i­dent spent much of last week stump­ing for on a trip to In­di­ana and on Twit­ter. That could give Repub­li­cans an open­ing to si­mul­ta­ne­ously scale back such Oba­macare taxes as the in­di­vid­ual and em­ployer man­dates and levies on the drug and de­vice in­dus­tries. “I won­der if we could see a grand com­pro­mise come for­ward in the months ahead as a tax bill is con­sid­ered,” said David Payne, a Repub­li­can strate­gist.

It’s un­clear if GOP lead­ers are will­ing

to at­tach Oba­macare pro­vi­sions to a tax bill and risk un­der­min­ing both leg­isla­tive pri­or­i­ties at once, other Repub­li­can strate­gists ar­gued.

With so much fo­cus on the failed re­peal ef­fort last week, health pol­icy in­sid­ers were dis­mayed that law­mak­ers seemed to for­get there were press­ing dead­lines to reau­tho­rize the Chil­dren’s Health In­sur­ance Pro­gram and en­sure con­tin­ued fed­eral fi­nanc­ing for com­mu­nity health cen­ters. Both mat­ters needed ac­tion by Sept. 30.

The chances that there will be ac­tion on ei­ther mat­ter so soon af­ter the de­feat of the re­peal bill are slim to none. “As they move on to things like the bud­get and tax re­form, health­care will be the for­got­ten stepchild,” Demo­cratic strate­gist Brad Ban­non said.

Both of those causes have bi­par­ti­san sup­port, so the ques­tions that re­main aren’t if fund­ing will be re­newed, but when, and what will the con­se­quences be for miss­ing the fis­cal year-end dead­line. Congress could pass a bill that retroac­tively funds both pro­grams from Oct. 1 to when­ever the law is signed by the pres­i­dent, but will it be too late?

Health cen­ters need fund­ing cer­tainty for staffing and con­tract­ing pur­poses, ac­cord­ing to Dan Hawkins, se­nior vice pres­i­dent for pol­icy and re­search at the Na­tional As­so­ci­a­tion of Com­mu­nity Health Cen­ters.

States, mean­while, need to fig­ure out if they’ll have money to cover chil­dren and preg­nant women un­der CHIP. Min­nesota of­fi­cials sent a let­ter to HHS in mid-Septem­ber say­ing they would be out of funds by Oct. 1 and would have to start end­ing cover­age for ben­e­fi­cia­ries as a re­sult.

At a broader level, for state law­mak­ers wish­ing to im­ple­ment con­ser­va­tive health re­form ideas, Med­i­caid 1115 and 1332 waivers may be their only re­course for now. Al­ready, sev­eral states have pend­ing re­quests to im­pose work re­quire­ments, life­time lim­its and drug tests on Med­i­caid ben­e­fi­cia­ries.

But even that path­way could be de­railed—or at least side­tracked—if con­tro­versy swirling around HHS Sec­re­tary Dr. Tom Price con­tin­ues, ac­cord­ing to Tevi Troy, a for­mer deputy HHS sec­re­tary in the Bush ad­min­is­tra­tion and the pres­i­dent of the Amer­i­can Health Pol­icy In­sti­tute. Price has been un­der fire for his use of pri­vate jets on the tax­payer’s dime. Trump was “not happy” with Price’s ac­tions and said, “We’ll see” Sept. 27 when asked by re­porters if he planned to fire the sec­re­tary. Late Sept. 28, Price an­nounced that he would re­im­burse the Trea­sury Depart­ment for us­ing the char­ter planes.

Oth­ers were not so sure what ef­fect Price’s exit would have on the CMS’ re­view and ap­proval of waiver re­quests.

“The per­son driv­ing waiver ef­forts is Seema Verma, and she ap­pears not to have an air­plane prob­lem,” said Emily Evans, a health pol­icy an­a­lyst at Hedg­eye Risk Man­age­ment.

AP PHOTO

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