Health care reform is far from over

Budget deadline likely to upstage any second passes at ACA repeal 

On March 24, House Speaker Paul Ryan cancelled the planned vote on the “American Health Care Act (AHCA),” a bill that would have repealed and replaced provisions of the Affordable Care Act (ACA) and severely cut federal funding for the Medicaid program.

Although multiple changes were made to the legislation in the final days to gain support from conservative and moderate factions within the House Republican caucus, in the end these were not enough. Still lacking the votes needed for a simple majority, the bill was pulled just before the scheduled vote on the House floor.

After Ryan, in a subsequent press conference, remarked that “Obamacare is now the law of the land” and President Trump signaled his desire to abandon the effort and move on to other priorities, many are asking what is next on the health care front.

Just a few days after the bill’s failure, Ryan appeared to reverse course, signaling that the House has not abandoned their attempts to overhaul the healthcare system, though he did not lay out a specific plan or timeline. Senate leaders have been less optimistic, while still acknowledging that if the House was somehow able to pass an ACA repeal and replace bill, they would consider it.

After the AHCA was pulled, health care overtook national security as the top priority for American voters, according to Morning Consult/POLITICO polling data, and members of Congress will likely be hearing more from their constituents when they return home to their districts for a scheduled two-week recess (April 10–21).

However, when they return, Congress will have only one week to pass a federal funding package to keep the federal government open past April 28, when the current continuing resolution is set to expire. In addition, Trump and Congressional leaders are simultaneously preparing major tax reform and infrastructure packages. It remains to be seen whether big-picture healthcare legislation can happen in the near term.

Experts agree that administrative actions from Department of Health and Human Services (HHS) Secretary Tom Price now present the most immediate opportunities and challenges for overhauling the health care system.

This was already the second of the “three buckets” identified as a part of the president and Congressional leadership’s comprehensive strategy to repeal and replace the ACA (the first bucket involved using the budget reconciliation process, as Republicans did with the AHCA, and the third bucket focuses on passing individual pieces of smaller legislation through regular order). Trump already signaled his intent to use administrative actions in the Executive Order that he signed on the first day of his administration, “Minimizing the Economic Burden of the Patient Protection and Affordable Care Act Pending Repeal.”

Even during the 17-day window in which the AHCA was being debated, the Trump Administration, under HHS Secretary Price, had already begun taking administrative action.

On March 13, Price sent a letter to governors encouraging states to apply for a new type of Medicaid waiver. Waivers can provide an opportunity for states to advance objectives of the Medicaid program that are not otherwise codified under federal law.

One particular waiver, called a Section 1332 waiver, will allow states to make changes to health insurance exchanges, qualified health plans, premium tax credits and cost-sharing subsidies, as well as to the individual and employer mandates.

On March 14, immediately after the Senate confirmed Seema Verma as the administrator of the Centers for Medicare and Medicaid (CMS), Price and Verma sent a joint letter to governors outlining their vision of the Medicaid program as one “where states have more freedom to design programs that meet the spectrum of diverse needs of their Medicaid population.” According to the National Association of Medicaid Directors, the letter lays out CMS’ intent to provide states additional flexibility in the Medicaid program to “support state efforts to promote employment and design programs which more closely align with private coverage. This includes consumer direction, enrollment in employer-sponsored health insurance, premium contributions, emergency room co-pays, and waivers of non-emergency medical transportation, retroactive eligibility, and presumptive eligibility.” Such efforts can be achieved under existing Section 1115 waivers, which provide the HHS Secretary broad authority to approve state Medicaid programs. 

Without legislation, however, other decisions must be made that impact the status of the health care system as it currently exists under the ACA. For example, the Trump Administration and Congress must determine how to stabilize the insurance markets. The AHCA included a $115 billion fund to do just this, so Congress now needs to decide if they will provide additional funding. In addition, they must determine whether to promote open enrollment in the individual marketplaces after deciding this past year to pull advertisements. Since many counties have struggled to attract more than one insurer, the Trump Administration must decide if it wants to get involved in helping to recruit new insurers.

Beyond appropriations, which will determine discretionary funding levels for everything from mental health and substance abuse services to public health, other must-pass healthcare legislation awaits even if Congress does not attempt another massive bill to repeal and replace the ACA. Federal funding for a whole suite of major health programs runs out at the end of September, including the Children’s Health Insurance Program (CHIP). Enacted in 1997, the CHIP program is administered similarly to Medicaid, and now covers approximately 9 million children — all from families with incomes that are modest but too high to qualify for Medicaid.

“One bill might be dead, but challenges with our nation's health care system are very much alive,” said NACo Executive Director Matthew Chase. “We are pursuing practical solutions to increase access to affordable health insurance and to make Medicaid more efficient and focused on those with the greatest need, including older adults, people with disabilities and children. The health of our residents is a top priority for counties nationwide.”

Chase emphasized the fundamental role counties play in health care: “Counties provide the local health safety net, and, in many cases, are required by law to provide health care to some of our most vulnerable residents.”

County governments play an integral role in the nation's health care system by paying for and providing health services, investing over $80 billion annually and working with private-sector and community providers.

Counties support 961 hospitals, 883 skilled nursing facilities, 750 behavioral health authorities and 1,943 public health departments. NACo will continue to work with the Trump Administration and Congress to ensure that any future changes to the nation's health care system do not simply shift federal and state costs to counties.

“We will work with Congress, the administration, states and other partners to ensure that counties can continue to serve our residents,” Chase said.

“We remain ready to identify strategies to strengthen our nation's health system by improving health outcomes and access to care while being responsible stewards of local taxpayer dollars.”