Remember the intense battle over abortion funding that nearly derailed the Affordable Care Act eight years ago? The same fight — almost to a T — has sent legislation to lower its health-plan premiums down in flames.
A massive $1.3 trillion spending deal lawmakers unveiled yesterday was, politically speaking, probably the last chance this year for Congress to try to help stabilize the Obamacare marketplaces, where around 10 million people buy coverage that has grown increasingly unaffordable.
By reimbursing insurers for extra cost-sharing discounts and losses from their sickest customers, the idea was to help bring down premiums for next year, something that’s generally a bipartisan goal. Sens. Lamar Alexander (R-Tenn.) and Patty Murray (D-Wash.) crafted just such a measure last fall, which they’ve since been trying to push through Congress in various spending bills.
But as this latest spending bill neared, Democrats and Republicans instead found themselves rehashing the same fight as in 2010, when they couldn’t agree on text to limit taxpayer funding of abortion. Republicans saw an opportunity to try for restrictions they’d pushed for but failed to gain the last time around. And Democrats were determined not to give them ground.
The stabilization bills were “being blocked in the omnibus bill for one reason and one reason alone,” Alexander told reporters yesterday. “Hyde language has applied since 1976. Every year Democrats have voted for it hundreds of times.”
The Hyde Amendment, always tacked onto appropriations bills, says federal funds can pay for an abortion only in cases of rape, incest or if the woman’s life is endangered. Republicans were insisting on applying it to the measures funding the cost-sharing reductions (CSRs) and reinsurance programs. They essentially want to prohibit any plans getting these funds from covering abortion, period.
Democrats, who wanted to preserve the ability of marketplace plans to cover abortions, rejected the Hyde language. They were willing to apply only the same language that currently governs the ACA’s premium subsidies. Under that language, marketplace plans covering abortions must collect an extra fee from customers and keep those funds separate to pay for the procedure.
The fight came to a head over the past week, as Alexander and Murray clashed over which language to include. Lobbyists told me that multiple versions of the legislation were considered and then discarded, and despite an intense effort from the insurance industry to broker a compromise, the whole thing fell apart over the weekend after Vice President Pence started pressuring Alexander to stand his ground. Alexander's office said only that characterization of any of the senator's conversations with Pence was inaccurate.
Murray and Democrats were further infuriated when Alexander took it a step further Monday, abandoning all pretense of working with them and instead teaming up with three GOP colleagues — Sen. Susan Collins of Maine and Reps. Greg Walden of Oregon and Ryan Costello of Pennsylvania — to roll out a stabilization bill that contained provisions overriding parts of the ACA that Murray had never agreed to originally.
“It's unfortunate that Sen. McConnell and Speaker Ryan have time and time again rejected bipartisan work on healthcare in favor of partisan healthcare politics, and chosen politically-driven show votes over getting a result for families,” Murray said in a statement yesterday.
Of course the Republicans had their own take:
It has all reopened a deep wound for antiabortion Republicans, who have long felt they lost their battle over attaching Hyde to the premium subsidies when the ACA was passed. While some conservative states have banned federally subsidized marketplace plans from covering abortions even if the funds are kept separate, plans in many other states include it in their list of benefits.
“I think the Democrats basically decided they would rather have subsidies for plans with abortion coverage rather than have cost-sharing reductions and reinsurance to drive down premiums,” David Christensen, a lobbyist for the Family Research Council, told me.
Some states, including California and Washington, require plans to cover the procedure. Insurers in these states were concerned they would be stuck between a rock and a hard place if Hyde restrictions were attached to the CSRs and reinsurance, because they could become ineligible for the payments.
Of course, there were lots of other disputes besides abortion undergirding the fight over stabilizing the marketplaces, such as how much leeway to give states in exempting plans from Obamacare coverage requirements and whether to boost the premium subsidies low-income Americans can get.
But despite all the yelling in Washington over the past nine months about how important it was to help marketplace insurers bring down premiums, lawmakers on either side of the aisle just didn’t see enough political advantage to coming together to get them passed in the end.
From Democrats’ perspective, Republicans now “own” the ACA and can be blamed for any future premium hikes. And while it’s true Republicans face that risk in an election year, several recent reports have underscored the reality that insurers actually fared much better than expected without the extra payments.
Yesterday, the White House highlighted a report from the Council of Economic Advisers finding that even after a few rough years in the marketplaces, and the end of two other programs that protected insurers with the biggest losses, private insurers are enjoying bigger profit margins chiefly driven by the law’s Medicaid expansion and their own ability to adjust to the new pool of enrollees.
“Insurers, despite the expiration over a year ago of the reinsurance and risk corridors programs which were meant to financially protect insurers, have started to make higher profits again,” the council wrote.
Politico’s Paul Demko reported last week that many of the remaining marketplace insurers made money for the first time last year, based on an analysis of the financial filings of 29 Blue Cross Blue Shield plans, which have seen the most individual market success in recent years.
And marketplace insurers are worried that restoring the CSR payments could result in major disruption and sticker shock for consumers getting subsidies, the Robert Wood Johnson Foundation found in a report it released Monday.
Even some leading ACA advocates have been urging the payments not be made after all, given the way insurers responded to losing them. Families USA, a liberal consumer group that was instrumental in getting the health-care law passed in 2010, has been pointing to an unexpected outcome when the Trump administration cut off the cost-sharing reduction payments last year.
Many insurers compensated for the loss by hiking premiums for mid-grade “silver” plans. Since federal subsidies are based on silver plan costs, many low-income Americans got more financial assistance to pay their monthly premiums. So if the CSRs were funded, it would reduce federal subsidy payments by $27 billion a year.
“Even though few anticipated this result, an extra $27 billion a year is now helping low-wage workers and middle-class families pay for health insurance,” Families USA’s Stan Dorn wrote in a recent analysis. “Policymakers should not eliminate that assistance based on nothing more than theoretical hopes of future arrangements that observers find more elegant and rational.”
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— Last night's release of the 2,000-plus-page spending bill touched off a legislative sprint as lawmakers try to pass it before Friday night, the deadline to avoid a government shutdown, The Post's Mike DeBonis and Erica Werner report. It remains uncertain whether they will be able to meet the challenge, amid multiple plot twists as the deal came together. As aides hashed out its final details on Wednesday afternoon, Trump’s support for the emerging compromise was suddenly cast into doubt, forcing House Speaker Paul Ryan to rush to the White House early Wednesday afternoon to allay the president’s concerns.
“The members know what is at stake,” House Majority Whip Steve Scalise (R-La.) said late Wednesday after leaving House meetings during which his whip team began counting votes for the bill. “We have to pay our troops and support our president.”
So what other health-care stuff made it in? The Department of Health and Human Services would get a significant funding boost, receiving $98.7 billion compared to $87.1 billion in 2017. A big part of the difference is due to new opioids funding, with lawmakers providing $2.6 billion in new funding specifically for HHS and doubling to $1 billion a state block grant program. Substance abuse block grants would also be increased from $2.9 billion to $3.4 billion and mental health block grants would get $1.4 billion, up from $1.1 billion last year.
The National Institutes of Health is also a big winner here. The research agency would receive a $3 billion increase over its $34.1 billion allotment last year, including $500 million extra for research into opioid addiction and $414 million extra for Alzheimer's disease research. That prompted big cheers from lawmakers across the political spectrum last night. As for the CDC, it also gets a funding boost but a long-standing, controversial prohibition on research that could be used for advocating gun control remains. Instead, lawmakers added language clarifying "the CDC has the authority to conduct research on the causes of gun violence," indicating there's not a blanket ban on such research.
-- On its second try, the House yesterday passed "Right to Try" legislation giving terminally ill patients the ability to try unproven experimental treatments. Debate over the bill, which passed the House 267 to 149, pitted Republican lawmakers, Trump and Pence against Democrats, patient groups and four former commissioners of the Food and Drug Administration, my colleague Elise Viebeck reports.
"Supporters described the measure as a compassionate effort to provide access to treatments that could extend the lives of the terminally ill," Elise writes. "Opponents argued the bill would allow bad actors to exploit vulnerable patients using treatments with largely unknown effectiveness and side effects."
The legislation initially failed last week after Republicans brought it to the floor under suspension of the rules, an approach typically reserved for noncontroversial bills that requires two-thirds support for passage. Yesterday's vote required only a simple majority for passage. The bill now needs approval from the Senate, which passed its own version over the summer by unanimous consent. Thirty-eight states have approved similar measures, and it now seems likely a national version will make it into law, with strong support by the administration.
AHH: Robert Redfield, a leading AIDS researcher who is well respected for his clinical work but has no experience running a governmental public-health agency, was named yesterday to head the CDC, The Post's Lena H. Sun reports. Health and Human Services Secretary Alex Azar said in a statement that Redfield, a 66-year-old virologist and physician, has “dedicated his entire life to promoting public health and providing compassionate care to his patients, and we are proud to welcome him as director of the world’s premier epidemiological agency.”
"The decision had been expected since Redfield emerged late last week as the front-runner to become CDC director, a job for which he also was considered when George W. Bush was president," Lena writes. "The position does not require Senate confirmation, and Redfield, a professor of medicine at the University of Maryland School of Medicine and a former Army researcher, is expected to be sworn in and take up his job in only a few days."
Redfield’s main focus during his career has been chronic human infections, especially HIV/AIDS. He heads clinical care and research at the medical school’s Institute of Human Virology and also oversees a major program providing care to more than 6,000 patients in the Baltimore-Washington region, and more than 1.3 million patients in Africa and the Caribbean as part of the President’s Emergency Plan for AIDS Relief, known as PEPFAR.
Maryland Democrats praised Redfield’s selection. Rep. Elijah Cummings called him a “deeply experienced and compassionate public health physician." Former Maryland Lt. Gov. Kathleen Kennedy Townsend said, “It’s terrific to have someone who has been such a caring doctor, who has really treated patients and knows what they’re going through.”
OOF: Democratic lawmakers have blocked legislation aiming to broaden access to private sector health-care for veterans, a measure which has been a priority for Trump. The Caring for Our Veterans Act increase the use of community health care and long-term care for veterans by broadening eligibility for such care and allowing VA to enter into agreements with health care providers in the private sector without complying with the Federal Acquisition Regulation.
Earlier this week, it seemed the measure was headed into the budget with a plan that was backed by the White House and some veterans advocacy groups. But House Minority Leader Nancy Pelosi (D-Calif.) objected and it was left out of the spending deal announced yesterday, our colleague Emily Wax-Thibodeaux reports. Pelosi and other Democrats said they're “concerned that the bill would diminish congressional oversight of the VA, that it would go too far in outsourcing care and that it would not address some of agency’s biggest problems,” Emily writes.
OUCH: In the last 14 months, hundreds of prescription medications have seen a significant price spike even as the Trump administration promises to tackle high drug prices. An analysis from Pharmacy Benefits Consultants found that from January 2017 to March 2018, 20 drugs saw a price increase of more than 200 percent, 39 drugs saw at least a 100 percent spike and one – a prescription skin cream – jumped 1,468 percent, Axios’s Bob Herman reports. Some of the most popular painkillers, including Purdue Pharma's OxyContin and Endo Pharmaceuticals' Percocet also saw a 20 percent or more increase.
“These are increases in the drugs' list prices, before rebates and discounts are applied. People with insurance don't pay these full amounts, but price hikes still affect everyone — co-pays and deductibles are often based on drugs' list prices, and uninsured patients can find themselves on the hook for a drug's entire list price,” Bob explains.
— The Health 202 wrote this week about how President Trump, as part of his opioids approach, is calling for the death penalty for drug crimes, as allowed under law. But because federal prosecutors haven't pursued capital punishment for drug smugglers, there was a lot of uncertainty about exactly what he meant. In a memo to U.S. attorneys yesterday, Attorney General Jeff Sessions provided more clarification about how the administration wants to ramp up prosecutions.
Sessions pointed to four federal statutes prosecutors could use to seek capital punishment: certain racketeering activities, the use of a firearm resulting in death during a drug trafficking crime, murder in furtherance of a continuing criminal enterprise and dealing in extremely large quantities of drugs. “I strongly encourage federal prosecutors to use these statutes, when appropriate, to aid in our continuing fight against drug trafficking and the destruction it causes in our nation,” he wrote.
Sessions also called on federal prosecutors to designate an opioid coordinator in every district and use all “criminal and civil remedies available under federal law to hold opioid manufacturers and distributors accountable for unlawful practices.”
—The administration's death penalty focus has attracted significant criticism from those aware of how disproportionately people of color are sentenced to execution, The Washington Post's Eugene Scott writes. Data show African Americans are overrepresented in the country's execution chambers. Although they make up 12 percent of the U.S. population, they represent 34 percent of those executed since the 1970s, according to “Death Row USA,” a report by the NAACP Legal Defense Fund.
—A few more good reads from The Post and beyond:
- The Alliance for Health Policy, the Association of Health Care Journalists and the National Institute for Health Care Management hold a webinar.
During his first speech on the Senate floor, Sen. Doug Jones (D-Ala.) said “we have to require background checks on all gun sales:"
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Lawyers for adult film star Stormy Daniels and President Trump's lawyer traded barbs on CNN for nearly 30 minutes: