Coming off the long August recess and still fresh from unsuccessful health reform efforts in July, Senate leaders are considering smaller, bipartisan fixes to the Affordable Care Act (ACA) while another group of senators are simultaneously making one last attempt to repeal and replace the ACA. Time is of the essence, as the Senate Parliamentarian recently ruled that the ability of Republicans to fast-track the bill under budget reconciliation, which only requires a simple majority vote, expires on September 30.
The push to make bipartisan improvements to the health law has been a joint effort between Chairman of the Senate’s Health, Education, Labor and Pensions (HELP) Committee Lamar Alexander (R-Tenn.) and his Democratic counterpart Patty Murray (D-Wash.). Last week, after Congress returned from its summer recess, the HELP Committee held the first of four public hearings on ways to stabilize health insurance premiums and bolster the individual insurance market for 2018.
Both Democrats and Republicans agree there needs to be sustained funding for the ACA’s cost-sharing reduction (CSR) subsidies, which reimburse insurers for providing discounted deductibles and co-pays to low-income patients. Insurers have been receiving these payments on a month-by-month basis, though the ACA repeal and replace efforts have created uncertainty in the insurance markets. Insurers who want to participate in the federal insurance marketplace in 2018 must sign contracts with the federal government by September 27.
Despite senators’ bipartisan consensus on certain insurance issues, the hearings—the third of which was held today—highlight points of disagreement between Republicans and Democrats. Democrats want the CSR payments to be paid out for more than just a year and have also asked for the reinstatement of funding (recently cut by President Trump) for advertising open enrollment in the federal insurance marketplaces.
In exchange for providing funding for the CSRs, Republicans want to make it easier for states to waive key ACA requirements via what are known as Section 1332 Waivers. Therefore, it remains unclear whether the HELP Committee can secure the necessary support to produce a “small, balanced stabilization bill” by end of this month.
Meanwhile, the White House continues to push for the repeal of the ACA and is pressuring Republicans in Congress to act. Sens. Bill Cassidy (R-La.) and Lindsey Graham (R-S.C.) are set to release a bill that would repeal much of the ACA and replace it with lump sum payments to states. While legislative text has not been released, it is being reported that the proposal would set aside $1.2 trillion in state block grants by 2026 to be used for Medicaid expansion and private insurance subsidies, leaving in place major parts of the ACA until 2020.
The clock is ticking on both efforts, especially since the window to pass healthcare legislation with 50 Senate votes will expire on September 30. In addition to finalizing legislative text, the Congressional Budget Office (CBO) would need to analyze any proposals—a process that can take two weeks—and Republicans would have to work to reach consensus and secure the necessary votes. Otherwise, any such legislation would have to proceed through regular legislative order, requiring votes from Democrats to reach the normal 60 vote threshold.
Beyond ACA repeal, replace and/or repair efforts, federal authorization for a series of key health programs expire at the of this month. Programs of most relevance to counties that need reauthorization include the Children’s Health Insurance Program (CHIP), the Maternal, Infant, Early Childhood Home Visiting (MIECHV) Program, Community Health Center funding and Disproportionate Share Hospital (DSH) reductions. The Senate’s passage of a short-term continuing resolution (CR) combined with lifting the debt ceiling through December 8 makes this process much more difficult. As Congress looks to pivot toward tax reform – and the 2018 elections – the appetite for passing health legislation this year is quickly fading.
As Congress deliberates on health care reform, NACo will continue to engage with federal lawmakers to ensure that county interests are represented in any legislative proposals.
Additional NACo resources on health care: