Three ways Repub­li­cans could bet­ter re­form the ACA

The Denver Post - - PERSPECTIVE - By Mike Coff­man

In last Sun­day’s Den­ver Post, John In­gold wrote a front page story en­ti­tled “The Faces of Med­i­caid.” In this story he com­pas­sion­ately de­scribed a lit­tle girl who was dis­abled, a boy with se­vere autism and a se­nior suf­fer­ing from the Alzheimer’s dis­ease. In­gold high­lighted their de­pen­dence on Med­i­caid, a shared fed­eral/state part­ner­ship that pro­vides a health care safety net for the poor and dis­abled. The Repub­li­can-led Congress is now con­sid­er­ing sig­nif­i­cant re­forms to Med­i­caid due to its sky­rock­et­ing costs as part of ef­forts to re­peal and re­place the Af­ford­able Care Act (ACA), bet­ter known as Oba­macare.

His­tor­i­cally, Med­i­caid is a “shared” costs pro­gram with the states and the fed­eral gov­ern­ment each pay­ing about half its ex­penses. The Repub­li­can pro­posal moves Med­i­caid from its current ar­chaic fee-for-ser­vice sys­tem to one where states can choose to ei­ther ac­cept a fixed cap­i­tated amount per en­rollee, in­creased an­nu­ally by a for­mula of med­i­cal in­fla­tion plus one per­cent per year, or a block grant. Un­der the block grant, states would re­ceive much more flex­i­bil­ity in how they man­age the de­liv­ery of care for their Med­i­caid pop­u­la­tion and pro­vide re­lief to their bud­gets by re­duc­ing the cost of de­liv­er­ing med­i­cal care. How­ever, for vul­ner­a­ble pa­tients, like the ones high­lighted in The Post story last Sun­day, there re­mains the un­cer­tainty of how changes to Med­i­caid may im­pact their ac­cess to care. Not sur­pris­ingly, the un­cer­tainty of how changes to their care will af­fect them and their fam­i­lies has cre­ated an en­vi­ron­ment of anx­i­ety and fear of the un­known.

The irony of this is that none of the pro­grams de­scribed by In­gold were part of the ACA. What the ACA did was to cre­ate the Med­i­caid ex­pan­sion pro­gram. Med­i­caid ex­pan­sion added an en­tirely new class of re­cip­i­ents to Med­i­caid by mak­ing el­i­gi­ble able-bod­ied in­di­vid­u­als, with­out de­pen­dent chil­dren, who earn up to 138% of the fed­eral poverty level. The ACA’S Med­i­caid ex­pan­sion pro­gram has in­creased the num­ber of Med­i­caid en­rollees across the coun­try by al­most a third and is the main driver of Med­i­caid’s dra­matic in­crease in spend­ing.

On Tues­day, I sent a let­ter to Speaker of the House Paul Ryan and Se­nate Ma­jor­ity Leader Mitch Mccon­nell sug­gest­ing that Repub­li­cans re­visit their ap­proach to ACA re­form and break it into three sep­a­rate ini­tia­tives. The first would limit changes to Med­i­caid to only the Aca-cre­ated Med­i­caid Ex­pan­sion pro­gram and ap­ply any sav­ings as an off­set for the taxes and penal­ties that im­pact work­ing and mid­dle class fam­i­lies; the se­cond bill would move all other Aca-re­lated taxes out of the health care de­bate and into the pend­ing tax re­form bill; and the third would ad­dress the fail­ing health in­sur­ance ex­changes where in­di­vid­u­als not el­i­gi­ble for Med­i­caid and who do not have em­ployer pro­vided health in­sur­ance now go for cov­er­age. This part should be ne­go­ti­ated in a bi­par­ti­san man­ner out­side of the fil­i­buster-proof bud­get rec­on­cil­i­a­tion process.

Med­i­caid ex­pan­sion: As noted above, the tra­di­tional Med­i­caid pro­gram is a shared re­spon­si­bil­ity with costs di­vided about evenly be­tween the fed­eral gov­ern­ment and the states. Un­der the ACA, the Med­i­caid ex­pan­sion pro­gram has the fed­eral gov­ern­ment’s share start­ing at 100% and phas­ing down to 90% by 2020. It makes no sense to me that the fed­eral gov­ern­ment would fa­vor able-bod­ied adults over all other Med­i­caid re­cipi- ents, such as dis­abled chil­dren, whose costs are re­im­bursed at 50% by the fed­eral gov­ern­ment.

The ACA’S Med­i­caid ex­pan­sion needs to re­vert to the standard Med­i­caid cost shares that the states re­ceive for all other Med­i­caid en­rollees. This could be done by phas­ing it into ef­fect by al­low­ing all Med­i­caid ex­pan­sion en­rollees up to Jan­uary 2020 to re­main at the 90/10 split in­def­i­nitely while all new en­rollees from Jan­uary 2020 are at the standard re­im­burse­ment rate for each re­spec­tive state (50% in Colorado).

Tax re­form: There are 21 taxes and penal­ties in the ACA, many of which have noth­ing to do with health care. The ACA taxes on higher in­come Amer­i­cans, such as the 3.8% sur­tax on net in­vest­ment in­come, are bet­ter ad­dressed in the im­pend­ing tax re­form bill, not dur­ing the health care de­bate.

Health in­sur­ance re­form: The ACA promised lower health in­sur­ance rates but we all know that never ma­te­ri­al­ized. Now the health care ex­changes, cre­ated un­der the ACA, are fail­ing as health in­sur­ance car­ri­ers are los­ing money on the plans of­fered through the ex­changes — with more and more of them drop­ping out of the pro­gram. When there are no car­ri­ers will­ing to pro­vide poli­cies for a cer­tain state or re­gion ser­viced by an ex­change, the pro­gram col­lapses and con­sumers lose the abil­ity to buy in­come-ad­justed sub­si­dized poli­cies. I be­lieve this is an area where Repub­li­cans and Democrats can come to­gether to find a bi­par­ti­san so­lu­tion that works to lower health in­sur­ance costs while main­tain­ing con­sumer pro­tec­tions such as pre­ex­ist­ing con­di­tions.

Right now we in Congress have a bi­par­ti­san op­por­tu­nity to “fix” the many prob­lems Amer­i­cans have in ob­tain­ing ac­cess to af­ford­able health care and to re­spon­si­bly ad­dress the un­sus­tain­able cost of the ACA’S Med­i­caid Ex­pan­sion.

Mike Coff­man, a Repub­li­can, rep­re­sents Colorado’s 6th Con­gres­sional District.

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