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Coffee CAHC policy round-up: March 10, 2017

Coffee CAHC is a twice-weekly newsletter where we round up and comment on the latest health coverage policy developments both nationally and here in Maine. We hope you find these updates helpful!

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Coffee CAHC

115th Congress, 1st session

128th Maine Legislature, 1st session


March 10, 2017


TGIF, friends, amirite?! I tell you who’s probably VERY glad that it’s Friday, and that’s the members of the House Energy and Commerce committee, who…well, we’ll get to that. What are my exciting plans for the weekend? Oh, thanks for asking. I’m getting a haircut! …the fun never stops! (And, at about 1/17th the cost of an iPhone, it’s a bargain!) And hey, speaking of things that never stop (now, there’s my segue!)…


National level

After an all-nighter for Ways and Means and a twenty seven hour marathon session for Energy and Commerce, the two House committees have finished their markups of the two pieces of the reconciliation package that we talked about on Wednesday. By the end of it, committee members were openly offering bribes to each other, with committee vice-chair Joe Barton (R-TX) offering to buy every member of the committee breakfast at the Waffle House if they’d end the show. (Whoa now! Slow your roll there, big spender! If each of the 55 committee members spent $10 on breakfast, tax and tip would bring the breakfast bill up to about 1.1 iPhones!) Ultimately, though, every single proposed amendment in both committees was defeated, which means the bills that passed are identical to the ones we saw revealed earlier this week.

And that, dear readers, is good news for you, because it means that other than a few new glimmers of comprehension about how pieces of the bill might actually work and a couple of notes about how the optics of the whole thing have developed over the past day or two, there is…genuinely, and weirdly…not much new to report. No six-page Coffee CAHC today!

Despite (or maybe because of) having a few days to hear and learn more about the bill, despite the President ramping up the sales pitch, and despite Speaker Ryan going into full-on Professor Policy Wonk mode (hey, Mr. Speaker, that’s my job!), opposition certainly doesn’t seem to be showing any signs whatsoever of slowing down.

Meanwhile, we’re still waiting on the Congressional Budget Office (CBO) to release their score, including an estimate of how many people might lose coverage. I’m hearing rumors that the CBO score may drop on Monday (no link for that: for the first time ever, I have “a source”! So exciting!). But while we wait for CBO, Brookings Institute took a whack at it and came up with a stunning figure – 15 million, at least, will lose their coverage. And to be clear, that’s just from repealing the individual mandate. Brookings estimates “several million” more will lose coverage if Medicaid expansion ends. Yikes.

While all the action is currently in the House, we have to talk about the Senate. Not just because the list of Senators panning the House bill is up to something like a dozen, but because it’s actually the procedural rules of the Senate that teach us something about why this bill looks the way it does. When you get right down to it, the bill we have before us is designed in an attempt to pass muster with the Senate parliamentarian, who will decide whether or not the bill can pass through the “reconciliation” process, which means Senate Majority Leader Mitch McConnell can do it with 51 votes instead of the 60 that would be necessary to break a filibuster.

Even with that intent, there are some big questions about whether pieces of this will pass parliamentary muster. Remember, to use reconciliation, the bill has to directly impact the federal budget. It’s hard to see how a few of these provisions meet that standard – including, crucially, the continuous coverage requirement, which mandates individuals to make payments to insurance companies, not the government. Then again, even if the parliamentarian doesn’t sign off, Senator McConnell has other options to overrule or even fire the parliamentarian.

Hey, let’s talk about that continuous coverage requirement for a sec. Remember on Wednesday where I said this bill allows insurers to charge older enrollees premiums that are five times more than the youngest enrollees pay? And remember when I said that the “penalty” in this bill will be a 30% bump in premiums for a year if you go without coverage for more than 63 days? Right now, the penalty you pay for going without coverage adjusts based on your income. Under the replacement plan, it adjusts based the premiums you pay. See the problem yet? This means older enrollees be forced to pay more in premiums, at the same time that they get proportionally less in tax credits, which will also jack their penalty through the roof if they have a gap in coverage. If you’re over the age of 50, seriously, this bill is a nightmare.

Oh and by the way, take away the tax credit adjustments for geographic differences in premium rates, and our friends at Center on Budget and Policy Priorities estimate that Mainers will see an average 46% decrease in their tax credits, making us one of the hardest hit states in the country (put another way, Mainers will lose an average of 3.64 iPhones worth of tax credits annually).

So what happens now? The two bills passed by the two committees are headed for the Budget Committee in the House, which is scheduled to pick them up and “reconcile” them into a single package on Wednesday of next week. From there, it goes through the Rules Committee (a step I forgot about in Wednesday’s Coffee CAHC – apologies!), then on to the House floor. Any of these steps could result in an amendment, and one you want to keep an eye out for is a proposal to knock Medicaid expansion funding out in 2017 rather than 2020, as the bill is written. I’m hearing that leadership may be keeping that amendment in their pocket if they need a carrot to bring some conservative votes along, with the White House’s blessing – but remember, gaining conservative votes might mean shedding moderates. That’s particularly true in the Senate, where nixing Medicaid expansion is almost certainly going to cost more votes than Mitch McConnell can afford to lose.


State level

Short ‘n sweet today: nothing to report!


Would you like to know more?

It isn’t related to ACA repeal-and-replace, but some interesting rumblings from DC about Democrats and the Trump Administration searching for common ground on drug pricing.

A pair of must-reads from Vox: this explanation of the plan to overhaul Medicaid to a per-capita cap system, and another one of their marvelous cartoon explainers on the same topic.


Until next time, friends, I remain,


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