PART 1: THE SENATE
Congress has been on vacation since the beginning of August but that doesn’t mean they haven’t been doing anything. There have continued to be new developments in the healthcare debate since John McCain cast the deciding vote against the “skinny repeal” bill on July 28. And if you had to pick one word to describe both parties’ approaches to healthcare right now, a good choice would be “fractured.” That division creates the opportunity for health equity advocates to influence the direction and outcome of this debate, especially if we can leverage those groups in both the House and Senate that are saying they want bipartisanship.
Before we talk about our plan of action for moving forward as advocates, though, it’s helpful to take a look at where we are right now. A lot has gone on, so let’s take it one piece at a time, starting with a roundup of what has happened in the Senate in the few weeks since they voted, as well as what we can expect when they’re back in September.
(FYI, the House is in recess but technically the Senate is not. They are holding pro forma sessions—no business conducted—every three days, so President Trump can’t make any recess appointments.)
It’s easy to see how there might be one or two things other than healthcare occupying the minds of Senators. Congress needs to approve a spending bill quickly before the government runs out of money and has to shut down. There is also the question of the debt ceiling.
The top priority in September will be to avoid a government shutdown, which is hard to do when no one will listen to each other.
It hasn’t been clear whether healthcare will even be on the Senate’s radar when they return in September. Congress needs to approve a spending bill quickly before the government runs out of money on October 1 and has to shut down. It’s reasonable to say that Republicans and Democrats are not likely to easily agree on spending priorities, and even if they do agree on a bill we don’t know if the president will sign it (but we’ll get to that).
There is also the question of the debt ceiling, the amount of money the government is authorized by Congress to borrow. The U.S. is on track to hit the debt ceiling sometime in October, unless Congress passes a bill to raise it. Even getting close to hitting the debt ceiling can have serious consequences—that happened in 2011, and Standard & Poor’s downgraded the United States’ credit rating. (Just think about what it would mean to you personally to have a ding on your own credit history. Bad, right? Well, it’s not so good when it happens to a country either.) Unfortunately, there is a real risk that the far right will try to hold the debt ceiling hostage in an attempt to further their agenda, by attaching amendments to the bill that have nothing to do with the debt ceiling.
Meanwhile, President Trump is openly feuding with Senate Republicans generally and Majority Leader Mitch McConnell in particular. This infighting matters because conflict between the president (the leader of his party) and the lawmakers in his party can cause gridlock in the legislative process.
Also creating the potential for gridlock: Trump has said he will block any Senate spending bill that doesn’t include funding for his border wall and, in the process, will allow the government to shut down.
It’s easy to see how there might be one or two things other than healthcare occupying the minds of Senators.
BUT: Murkowski says bipartisan hearings on healthcare bills will go on.
Before the recess, Republican Lamar Alexander of Tennessee and Democrat Patty Murray of Washington announced that when they return, the Senate Health, Education, Labor and Pensions (HELP) Committee will begin holding bipartisan hearings on ways to stabilize the individual market in time for the 2018 enrollment period, and before the September 27 cutoff for insurance companies to sign contracts to participate in the marketplaces. (The good news is there are no more bare counties, meaning that in every county in the United States there is at least one insurer participating in the health insurance marketplace.)
Senator Lisa Murkowski of Alaska, a Republican and one of the votes that killed the Senate repeal bill in July, said earlier this week that the hearings will go on as planned. According to Murkowski, they will begin with a presentation from insurance commissioners and directors from across the country and will also include a panel of state governors.
Meanwhile, it looks like repeal and replace is back with a vengeance.
Back in early August, people were calling the bill drafted by Republicans Bill Cassidy of Louisiana and Lindsey Graham of South Carolina, and cosponsored by Dean Heller of Nevada, the “Last Plan Standing.” Andy Slavitt, a former acting administrator of the Centers for Medicare and Medicaid Services (CMS) calls it the “most significant threat” to the ACA in the Senate.
The Center for Budget and Policy (CBP) has said Graham-Cassidy-Heller would drastically cut Medicaid funding and marketplace subsidies and leave millions of low- and moderate-income people without access to insurance. The bill would replace current federal funding for insurance subsidies and Medicaid expansion with a block grant program, a strategy that has not proven successful for other safety net programs in the past because the flexibility of block grants allows states to use the money for other things. But in a Twitter thread explaining the strategy for getting the bill passed, Slavitt said, “[t]he punchline of Graham-Cassidy-Heller is not ‘block grants’—it’s a redistribution scheme of welfare payments to red states.”
Here’s how it works: Under the ACA, states that expanded their Medicaid programs were reimbursed by the federal government for 100% of the Medicaid costs they incurred between 2014 and 2016 for those people who became newly eligible. After 2016, the share of costs covered by the federal government for newly eligible enrollees gradually decreases to 90% by 2020. This is still a much higher rate than what the federal government usually gives states for Medicaid, meaning states that did not expand Medicaid get less money for each person participating in the program than those that did expand.
Under Graham-Cassidy-Heller, these financial supports for Medicaid expansion would be eliminated, along with subsidies that help lower income people who don’t qualify for Medicaid to purchase insurance through the marketplace. The funds would be redistributed to the 19 states that did not expand Medicaid as well as several other states that are also “lower cost” for one reason or another. Former Republican Senator Rick Santorum is one of the architects of this strategy, which he shared during an interview with Breitbart News that ran this week. (You can see a screen grab of part of the article here.) According to the CBP, the states that would suffer most under Graham-Cassidy-Heller would be those that were the most successful in enrolling low- and moderate-income people in coverage through their expanded Medicaid programs and marketplaces. But while the non-expansion states would see an increase in funding initially, they’d eventually see their funding decrease, too, since the block grants shrink over time and then end entirely after 2026.
Nevertheless, what makes this approach so powerful is that the plan can be sold to state governors, who want this money in their state budgets and who will put pressure on their Senators to vote yes.
Single payer is making an appearance. Democrats are split, but can we at least talk?
Bernie Sanders of Vermont, a Progressive Independent, plans to introduce a single-payer, “Medicare for All” bill when the Senate is back in session. Sanders himself admits the bill has no chance of passing, but according to a story by NPR, Sanders will introduce the bill in September to “force a conversation.”
The time might be right for that conversation. Heavy-hitters Elizabeth Warren of Massachusetts, Kamala Harris of California, and Kirsten Gillibrand of New York all now say they support Medicare for All, and New Jersey’s Corey Booker is warming up. (Source: Vox) Just as importantly, support for a single-payer plan is also gradually increasing among both the general public and doctors, in part due to frustration over the current debate. Even some Conservatives are saying that single-payer is beginning to look increasingly possible, although they’re not exactly happy about it.
The majority of Senate Democrats are still reluctant to support a bill that would implement a single-payer system all at once. But there could be an opening to start taking incremental steps toward single-payer, rather than jumping right in. Brian Schatz, Democratic Senator from Hawaii, told Vox in an interview posted on August 22 that he is working on a bill under which individual states could decide to allow uninsured people to buy in to the Medicaid program— which could be a first such incremental step. But, he said, he’ll also support a Medicare for All bill if it comes up for a vote.
There’s a lot here, and most of it warrants a deeper dive than we could take in this post to fully address the implications for health equity and equal access to care. But we still have other things to cover before we’re done with our roundup—and we will! In the next few posts, we’ll talk about:
- What the Members of the House have been doing since the end of July, where attempts at bipartisanship, repeal, and single-payer are underway.
- Other factors that could affect the 2018 enrollment period, including the elimination of federal support for enrollment assistance and the shortening of the enrollment period.
- An advocacy plan of action for when Congress returns in September.
PLUS What do you want to know more about? What did I miss? Where do you think we’re headed?
See you again soon on the #stairwaytohealthcare. Keep climbing!