McCon­nell has lit­tle in­ter­est in pur­su­ing health care mea­sure

The Buffalo News - - WASH­ING­TON NEWS -

tweets. He promised that any Repub­li­can health plan would pro­tect Amer­i­cans with pre-ex­ist­ing health con­di­tions, a ma­jor con­cern of vot­ers that Democrats ef­fec­tively ex­ploited in the 2018 midterm elec­tions.

After his election, Trump made sim­i­lar prom­ises, say­ing that the Repub­li­can pro­posal would be “far less ex­pen­sive and far bet­ter” than Oba­macare. The leg­is­la­tion that came later, and earned his en­dorse­ment, would have made in­sur­ance less ex­pen­sive, but only for cer­tain groups of young, high-in­come, healthy Amer­i­cans. The bills would have also elim­i­nated cov­er­age for mil­lions of peo­ple by scal­ing back Med­i­caid and would have made it harder for those with pre-ex­ist­ing ill­nesses – and those who are older with low in­comes – to find mean­ing­ful af­ford­able op­tions if they didn’t get in­sur­ance from work.

The three senators he has cho­sen to lead the ef­fort – Bill Cas­sidy of Louisiana, John Bar­rasso of Wy­oming and Rick Scott of Florida – have so far also de­clined to point to many specifics. When asked about an Oba­macare re­place­ment this week, they men­tioned their more mod­est bills to re­duce health care costs in the emer­gency room and at the drug­store. (A fourth se­na­tor the pres­i­dent has men­tioned, the ma­jor­ity leader, Mitch McCon­nell of Ken­tucky, has been even more clear that he has lit­tle in­ter­est in pur­su­ing com­pre­hen­sive health care leg­is­la­tion.)

One clue to Trump’s think­ing is the choice of Cas­sidy. Along with Sen. Lindsey Graham of South Carolina, he was the au­thor of a leg­isla­tive plan that re­ceived some scru­tiny in 2017 but never came up for a vote. An­other hint can be found in the pres­i­dent’s own bud­get, re­leased just be­fore his rein­vig­o­rated health care push. A third is a draft pro­posal de­vel­oped by a group of con­ser­va­tive Wash­ing­ton pol­icy groups.

Graham-Cas­sidy bill

The pres­i­dent has spo­ken fondly sev­eral times about this pro­posal, which did not have enough sup­port in Congress to ad­vance to a vote. It would elim­i­nate cur­rent pro­grams fund­ing Oba­macare’s Med­i­caid ex­pan­sion, which cov­ers the work­ing poor, and in­sur­ance sub­si­dies help­ing lowand mid­dle-in­come Amer­i­cans buy their in­sur­ance. In­stead, that money would be grouped to­gether, then parceled out to states to use in the ser­vice of health care pro­grams they fa­vor.

The leg­is­la­tion at­taches some rules to how the money can be used – it must go to­ward health care, for ex­am­ple –bu­tits­main­goal­isto­pro­vide states with max­i­mum flex­i­bil­ity to de­velop lo­cal and in­no­va­tive so­lu­tions. (Some ex­perts worry that states could strug­gle to de­velop such plans on the bill’s ab­bre­vi­ated timetable.)

That flex­i­bil­ity would al­low states, if they so chose, to waive Oba­macare’s rules that plans must cover a stan­dard set of med­i­cal ben­e­fits and that in­sur­ers must charge the same prices to cus­tomers with dif­fer­ent health his­to­ries. It would be easy for states to cir­cum­vent cur­rent pro­tec­tions for Amer­i­cans with pre-ex­ist­ing con­di­tions. That abil­ity would be at odds with the pres­i­dent’s re­cent prom­ises to pro­tect such rules.

The bill would also re­struc­ture the Med­i­caid pro­gram, even for pop­u­la­tions that were en­rolled in the pro­gram be­fore Oba­macare.

The bill’s for­mula for al­lo­cat­ing money among the states would also lead to big re­dis­tri­bu­tions, gen­er­ally tak­ing money away from states that have ex­panded Med­i­caid, to­ward those that have not. It would also re­strict the growth of the block grants over time. Those fund­ing for­mu­las, while tech­ni­cal, make a big dif­fer­ence in the im­pact of the pro­gram. It would re­sult in sub­stan­tial fund­ing short­falls for sev­eral large states nearly im­me­di­ately, and leave nearly ev­ery state in a fund­ing crunch over the long term.

The bud­get

Be­cause the 2020 White House bud­get was de­vel­oped and pub­lished by the White House it­self, it is per­haps the most use­ful clue about how the pres­i­dent imag­ines a world with­out Oba­macare.

Like the Graham-Cas­sidy pro­posal, it in­cludes block grants to the states to re­place the Oba­macare cov­er­age ex­pan­sion, and it re­places the re­main­der of Med­i­caid with a set of fixed pay­ments to states.

But the rate at which the dif­fer­ent grants would grow over time would be even smaller than un­der the leg­is­la­tion, “to make the sys­tem more ef­fi­cient.”

The bud­get is vague about what sorts of in­sur­ance reg­u­la­tions would be al­lowed, but it does note that a tenth of funds would need to be set aside for peo­ple with pre-ex­ist­ing con­di­tions, a sign that states would be al­lowed to ex­clude such peo­ple from the main­stream in­sur­ance mar­kets.

Her­itage pro­posal

A group of con­ser­va­tive health pol­icy ex­perts has de­vel­oped a health care pro­posal that shares a ba­sic struc­ture with the two sys­tems de­scribed above: It would hand states blocks of money and a few rules, and en­cour­age them to de­velop their own health care sys­tems.

The rules in the Her­itage plan dif­fer a bit from those in Graham-Cas­sidy. Her­itage would re­quire that gov­ern­ment-sub­si­dized sys­tems of­fer ev­ery Amer­i­can a choice of a pri­vate health plan, a re­quire­ment that would prob­a­bly fore­close a lib­eral state from en­act­ing a sin­gle-payer pro­gram and that might re­quire re­struc­tur­ing of some state-run Med­i­caid pro­grams.

The Her­itage plan shies away from spec­i­fy­ing fund­ing for­mu­las. It doesn’t say how the block of money should be divvied up among the states, though it says that states with more low-in­come res­i­dents should get a big­ger share. It also doesn’t spec­ify pre­cisely how quickly the pot of money should grow over time.

Like the bud­get pro­posal, it nods to con­cerns about Amer­i­cans with pre-ex­ist­ing con­di­tions by en­cour­ag­ing states to de­velop spe­cial pro­grams, like high-risk pools, to in­sure peo­ple with ex­pen­sive health needs. But it also en­cour­ages in­sur­ance strate­gies, like dis­counts for young cus­tomers, or stripped-down ben­e­fit plans, that would tend to make main­stream in­sur­ance less use­ful for peo­ple with se­ri­ous health needs.

The pro­posal also leaves the legacy Med­i­caid pro­gram as is. That choice neu­tral­izes one pos­si­ble po­lit­i­cal line of at­tack. But it also sub­stan­tially di­min­ishes the pro­gram’s pos­si­ble cost sav­ings.

The court case over the Af­ford­able Care Act will be de­cided on the ju­di­ciary’s timetable, so it’s not clear how long the White House may have to de­velop a re­place­ment plan. But, since it cer­tainly has at least months, there is time to de­velop some new pro­posal more aligned with the pres­i­dent’s re­cent prom­ises.

Do­ing so will not be easy, how­ever. Health care in the United States is ex­pen­sive, which means that health plans that cover ev­ery­one with low de­ductibles are likely to be costly. The block grant plans the pres­i­dent has ad­mired re­duce rather than in­crease cur­rent fed­eral spending on health care. Looser rules on health in­sur­ance are likely to in­crease costs on cus­tomers un­for­tu­nate enough to need care. That makes the block-grant ap­proach a trou­ble­some fit with the pres­i­dent’s stated de­sire for a sys­tem that Amer­i­cans find “far less ex­pen­sive & much more us­able than Oba­macare.”

New York Times

Pres­i­dent Trump has promised to un­veil a health care plan to re­place Oba­macare im­me­di­ately after the 2020 elec­tions, but de­tails about his pro­posal are lack­ing.

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