[NYAPRS Enews] Breaking: CBO Report Shakes GOP Support for Health Care Bill; 12 Key Findings

[Harvey Rosenthal]

NYAPRS Note: A newly released evaluation of the impact of the Senate healthcare bill is shaking GOP supporters and is, according to the Times, threatening to collapse the proposal's prospects. See highlighted areas below and the Modern Healthcare bullets at the bottom for more specifics.

CBO Report Complicates GOP Support for Health Care Bill
By Leigh Ann Caldwell NBC News<http://www.nbcnews.com/politics/congress/cbo-report-complicates-gop-support-health-care-bill-n776981>  June 27, 2017

WASHINGTON - A crucial week for the Senate health care bill got off to a difficult start for skittish Republicans struggling to muster support for the measure after the Congressional Budget Office released its analysis<http://www.nbcnews.com/politics/congress/cbo-senate-health-care-bill-would-leave-22-million-more-n776916> estimating that 22 million people would lose insurance under the law over the next decade.

Despite an initial addition<http://www.nbcnews.com/politics/congress/senate-gop-adds-new-penalty-uninsured-health-care-bill-n776841> to the measure Monday, Republicans continued to lay out demands for more changes to the bill, hoping leadership addresses their concerns. And a growing number of senators expressed deep apprehension with the bill Monday night, threatening GOP leadership's ability to even bring the measure up for a debate.

Sen. Susan Collins, R-Maine, announced via Twitter that the CBO report reaffirmed her fears about deep cuts to Medicaid in the Better Care Reconciliation Act and said she would vote against the "motion to proceed," a procedural vote that allows the Senate to bring up a piece of legislation to be debated and eventually voted on.

Sen. Rand Paul, R-Ky., also said he wouldn't vote for the motion to proceed, a vote expected to take place either Tuesday or Wednesday of this week.

"I won't vote to proceed to it unless the bill changes," Paul told reporters. "We have reached out to Senate leadership and said we would negotiate. We have had no phone calls from Senate Republican leadership."

Paul said the bill doesn't do enough to repeal the Affordable Care Act because it keeps subsidies - albeit less generous - to help individuals purchase health insurance and it keeps some of the coverage requirements imposed on insurance plans.

With no Democratic support, GOP leaders will need at least 50 of their 52 members to vote for the bill in order to advance it forward.

Sen. Ron Johnson, R-Wis., is a third senator who said that he could vote against the procedural motion this week, saying he "would highly doubt" that he would support it. He had previously urged the Senate to slow down the process to give senators time to debate and process the bill's impacts.

Those three senators, who oppose the measure for a variety of reasons, join Sen. Dean Heller, R-Nev., who announced last week that he would oppose the procedural vote because, like Collins, is against the measure's deep cuts to Medicaid.

At least two other Republicans, Sens. Ted Cruz, R-Texas and Mike Lee, R-Utah, expressed opposition to the bill as it stood when unveiled last week.

But the frenzied process of trying to appease the critics is underway. One change to the measure was already made to address concerns of some senators and health care experts who said the bill doesn't incentivize continuous health care coverage.

The change penalizes people who go without health insurance for 63 consecutive days, prohibiting them from purchasing a new plan for six months. Democrats called the idea "inhumane."

But Sen. Lindsey Graham, R-S.C. warned against special deals with individual senators in an effort to win their support. Because the CBO said that the bill saves $321 billion over a decade, that gives Republicans a significant pot of money to woo Republicans to their side.

"The best way to lose me on this bill is to start buying people off," Graham told reporters. "So that's what I'm really suspicious of as we get closer to Monday are they going to do special deals for Senators in particular states to get their vote. We've seen that movie before with Obamacare and in many ways this is very similar to the process we used on Obamacare, I don't particularly like it that much."

The White House is also involved in the lobby effort. Vice President Mike Pence invited four skeptical conservatives to his home Tuesday night for dinner. And President Donald Trump has been calling members. And in a persuasion tactic that might backfire, a pro-Trump super PAC is running a seven figure advertising campaign against Heller in Nevada who is up for re-election in 2018.

Health-related groups have been coming out en masse to oppose the Republican bill, including the American Medical Association, which came out with its scathing reaction Monday.

"Medicine has long operated under the precept of Primum non nocere, or 'first, do no harm.' The draft legislation violates that standard on many levels," Dr. James L. Madara, CEO of the AMA, wrote in a letter to McConnell.

While the CBO convinced Collins that the bill was no good for Maine, some Republicans denounced the 40-year old non-partisan Congressional analysts as not being very good at their job.

"The CBO has consistently proven it cannot accurately predict how healthcare legislation will impact insurance coverage," the White House said in a statement. "We know the facts."

Democrats, meanwhile, are launching an aggressive offensive against the Republican plan, expecting a vote this week. Like they did last Monday, they are "holding" the Senate floor late into the evening, with senators speaking back-to-back against the bill.

Sen. Mazzie Hirono of Hawaii is leading off tonight's "talk-a-thon" on the Senate floor on the eve that she leaves town to undergo surgery for cancer. "This bill is as bad as we thought it was," Hirono said of the CBO score.

http://www.nbcnews.com/politics/congress/cbo-report-complicates-gop-support-health-care-bill-n776981
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Senate Health Bill Reels as C.B.O. Predicts 22 Million More Uninsured
By Thomas Kaplan And Robert Pear  New York Times June 26, 2017

WASHINGTON - The Senate bill to repeal the Affordable Care Act was edging toward collapse on Monday after the nonpartisan Congressional Budget Office said it would increase the number of people without health insurance<http://topics.nytimes.com/top/news/health/diseasesconditionsandhealthtopics/health_insurance_and_managed_care/index.html?inline=nyt-classifier> by 22 million by 2026.

Two Republicans, Senators Susan Collins of Maine and Rand Paul of Kentucky, said Monday that they would vote against even debating the health care bill, joining Senator Dean Heller of Nevada, who made the same pledge on Friday. Senator Ron Johnson of Wisconsin hinted that he, too, would probably oppose taking up the bill on a procedural vote expected as early as Tuesday, meaning a collapse could be imminent.

"It's worse to pass a bad bill than pass no bill," Mr. Paul told reporters.

Ms. Collins wrote on Twitter<https://twitter.com/SenatorCollins/status/879471862694256641> on Monday evening that she wanted to work with her colleagues from both parties to fix flaws in the Affordable Care Act, but that the budget office's report showed that the "Senate bill won't do it."

The report<https://www.cbo.gov/publication/52849> left Senator Mitch McConnell of Kentucky, the majority leader, with the unenviable choices of changing senators' stated positions, withdrawing the bill from consideration while he renegotiates, or letting it go down to defeat - a remarkable conclusion to the Republicans' seven-year push to repeal President Barack Obama's signature domestic achievement.

But the budget office put Republicans in an untenable position. It found that next year, 15 million more people would be uninsured compared with current law. Premiums and out-of-pocket expenses could shoot skyward for some low-income people and for people nearing retirement, it said.

The legislation would decrease federal deficits by a total of $321 billion over a decade, the budget office said.

Mr. McConnell, the chief author of the bill, wanted the Senate to approve it before a planned recess for the Fourth of July, but that looks increasingly doubtful. Misgivings in the Republican conference extend beyond just a few of the most moderate and conservative members, and Mr. McConnell can lose only two Republicans.

At least some of Ms. Collins's concerns could be shared by Senators Lisa Murkowski of Alaska and Shelley Moore Capito of West Virginia, whose rural states would face effects similar to those in Maine.

"If you were on the fence, you were looking at this as a political vote, this C.B.O. score didn't help you," said Senator Lindsey Graham, Republican of South Carolina. "So I think it's going to be harder to get to 50, not easier."

He added, "I don't know, if you delayed it for six weeks, if anything changes."

Under the bill, the budget office said, subsidies to help people buy health insurance<http://topics.nytimes.com/top/news/health/diseasesconditionsandhealthtopics/health_insurance_and_managed_care/index.html?inline=nyt-classifier> would be "substantially smaller than under current law." And deductibles would, in many cases, be higher. Starting in 2020, the budget office said, premiums and deductibles would be so onerous that "few low-income people would purchase any plan."

Moreover, the report said, premiums for older people would be much higher<https://www.nytimes.com/2017/06/26/upshot/a-few-bright-spots-for-republicans-the-rest-could-be-scored-as-grim.html> under the Senate bill than under current law. As an example, it said, for a typical 64-year-old with an annual income of $26,500, the net premium in 2026 for a midlevel silver plan, after subsidies, would average $6,500, compared with $1,700 under the Affordable Care Act. And the insurance would cover less of the consumer's medical costs.

Likewise, the report said, for a 64-year-old with an annual income of $56,800, the premium in 2026 would average $20,500 a year, or three times the amount expected under the Affordable Care Act.

The budget office report was a major setback to Senate Republican leaders, but it was too early to declare the legislation dead, and turmoil in health insurance markets could still induce Congress to take action this year. Many people thought the House repeal bill was dead after Speaker Paul D. Ryan pulled it from the floor<https://www.nytimes.com/2017/03/24/us/politics/health-care-affordable-care-act.html> on March 24, but a slightly revised version was narrowly approved by the House six weeks later.

Senator John Thune of South Dakota, a member of the Republican leadership, suggested that leaders would press forward with the Senate bill. He said that an argument could be made for delaying it "if you thought you were going to get a better policy," but that that was not the case.

"This is the best we can do to try and satisfy all the different perspectives in our conference," Mr. Thune said, adding that he did not think the politics would improve by waiting. "It's time to fish or cut bait."

The White House discounted the report, saying the budget office had "consistently proven it cannot accurately predict how health care legislation will impact insurance coverage."

The Trump administration says the Senate Republican bill would not cut Medicaid<http://topics.nytimes.com/top/news/health/diseasesconditionsandhealthtopics/medicaid/index.html?inline=nyt-classifier> because spending would still grow from year to year.

But the Congressional Budget Office said that the bill would reduce projected Medicaid spending by a total of $772 billion in the coming decade, and that the number of people covered by Medicaid in 2026 would be 15 million lower than under current law.

In 2026, it said, Medicaid spending would be 26 percent lower than under current law, and enrollment of people under 65 would be 16 percent lower. Beyond 2026, Medicaid enrollment would keep declining compared with what would happen under current law.

The Senate bill would make it much easier for states to obtain waivers exempting them from certain federal insurance standards, like those that require insurers to provide a minimum set of health benefits. The budget office said that nearly half of all Americans could be affected by these cutbacks in "essential benefits," and that as a result, coverage for maternity care, mental health<http://topics.nytimes.com/top/news/health/diseasesconditionsandhealthtopics/mentalhealthanddisorders/index.html?inline=nyt-classifier> care, rehabilitation services and certain very expensive drugs "could be at risk."

Before the budget office released its report, the American Medical Association had announced its opposition<https://searchlf.ama-assn.org/undefined/documentDownload?uri=%2Funstructured%2Fbinary%2Fletter%2FLETTERS%2FBCRA-Letter.pdf> to the bill, and the National Governors Association had cautioned the Senate<https://www.democraticwhip.gov/sites/default/files/6.23.17%20NGA%20HHS%20BCRA.PDF> against moving too quickly.

The budget office's findings immediately gave fodder to Democrats, who were already assailing the bill as cruel. Senator Chuck Schumer of New York, the Democratic leader, said Senate Republicans had been saying for weeks that their bill would be an improvement over the House bill, which President Trump had described as "mean."

The budget office had found<https://www.nytimes.com/2017/05/24/us/politics/cbo-congressional-budget-office-health-care.html> that under the House bill, the number of people without health insurance would increase by 23 million by 2026 - only slightly more than the 22 million projected for the Senate bill.

"C.B.O.'s report today makes clear that this bill is every bit as mean as the House bill," Mr. Schumer said. "This C.B.O. report should be the end of the road for Trumpcare. Republicans would be wise to read it like a giant stop sign, urging them to turn back from this path that would be disastrous for the country, for middle-class Americans and for their party."
[https://static01.nyt.com/images/2017/06/21/us/cbo-score-of-senate-health-care-bill-1498510485739/cbo-score-of-senate-health-care-bill-1498510485739-master495.png]

The criticism was not confined to the Democratic caucus. Mr. Johnson, one of five Senate Republicans who said last week that they could not support the bill as drafted, told a radio host that Senate leaders were "trying to jam this thing through." He, too, suggested he would not vote even to begin debating the bill.

"I have a hard time believing I'll have enough information for me to support a motion to proceed this week," Mr. Johnson said later on Monday.

Beyond the number of Americans without insurance, the Senate bill's $321 billion in deficit reduction is larger than the $119 billion that the budget office found for the bill that passed the House.

Earlier Monday afternoon, Senate Republican leaders altered their bill to penalize people who go without health insurance by requiring them to wait six months before their coverage would begin. Insurers would generally be required to impose the waiting period on people who lacked coverage for more than about two months in the previous year.

The waiting period was meant to address a notable omission in the Senate's bill: The measure would end the Affordable Care Act's mandate that most Americans have health insurance, but also require insurers to accept anyone who applied. The proposal is supposed to prevent people from waiting until they get sick to buy a health plan. Insurers need large numbers of healthy people, whose premiums help defray the cost of care for those who are sick.

Under one of the most unpopular provisions of the Affordable Care Act, the government can impose tax penalties on people who go without health coverage. Republicans have denounced this as government coercion.

The repeal bill passed by the House last month has a different kind of incentive. It would impose a 30 percent surcharge on premiums for people who have gone without insurance.

Mr. Trump wrote on Twitter on Monday that Republican senators were "working very hard to get there" but were not getting any help from Democrats.

"Not easy! Perhaps just let OCare crash & burn!" Mr. Trump wrote<https://twitter.com/realDonaldTrump/status/879326984794517507>, reiterating his assertion that the Affordable Care Act would be doomed if Congress did not come to its rescue.

https://www.nytimes.com/2017/06/26/us/politics/senate-health-care-bill-republican.html
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13 key CBO findings on the Senate GOP Repeal Bill
By Harris Meyer  Modern Healthcare  June 26, 2017

1. 22 million fewer Americans <https://www.cbo.gov/publication/52849> would have health insurance in 2026 compared with current law, slightly less than the estimated 23 million<http://www.modernhealthcare.com/article/20170524/NEWS/170529946> who could lose coverage under the House GOP bill (the American Health Care Act).

2. 15 million more people would be uninsured in 2018, largely due to elimination of the Affordable Care Act's tax penalty for not having insurance.

3. An estimated 49 million people would be uninsured by 2026, compared with 28 million under current law.

4. The aggregate federal deficit would be reduced by $321 billion from 2017 to 2026, compared with a $119 billion reduction under the AHCA.

5. Federal Medicaid spending would decrease by $772 billion, or 26% over 10 years, compared with an $834 billion reduction under the AHCA.

6. Medicaid enrollment would fall by about 16% by 2026 among people under age 65.

7. The repeal of the Affordable Care Act's tax provisions would cost $541 billion in lost revenue over 10 years.

8. The individual insurance market in most parts of the country would "continue to be stable" in 2020 and beyond, as it would under the ACA.

9. Insurance covering certain services would become more expensive in some areas due to state waivers from essential benefit requirements that would affect nearly half the U.S. population.

10. Individual-market average premiums would rise faster than under current law prior to 2020, then rise more slowly thereafter; by 2026 average premiums would be about 20% lower, largely because plans would pay for less and because of federal funding to directly reduce premiums.

11. Few low-income people would buy insurance starting in 2020 because the lower actuarial value for benchmark plans would lead to significantly higher deductibles.

12. People who need services no longer included in essential benefits in states that waived ACA rules would experience substantial increases in out-of-pocket spending or would forgo those services.

13. In states that waived essential benefits, some people could see large increases in out-of-pocket spending because annual or lifetime benefit limits for some services would no longer be capped.

Source: Congressional Budget Office/Joint Committee on Taxation cost estimate of the Better Care Reconciliation Act of 2017.

http://www.modernhealthcare.com/article/20170626/NEWS/170629911?utm_source=modernhealthcare&utm_medium=email&utm_content=20170626-NEWS-170629911&utm_campaign=am
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