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Coffee CAHC policy round-up: May 17, 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


Wednesday, May 17, 2017


I know you all look forward every week to the latest updates (right? …right?) and I know you can’t wait to hear the latest. And yes, usually I put a weather-related comment in the prologue section here, and, yes, the weather today is gorgeous. But I know you probably can’t wait for the single most important update since Friday’s edition, so let me get that out of the way right now:

The Mother’s Day lobster was delicious.


National level

What an abrupt shift from a few weeks ago, to have the national updates section be so anemic.

But to be clear, just because this section isn’t packed with new developments does not mean that nothing is going on; it just means that the AHCA process is in a phase where most conversations are taking place behind closed doors, and we’re going off of whatever careful snippets and updates get released.

So far, I’d say the process in the Senate has certainly been a lot more restrained than the House process, where a lot of the negotiations seemed to be taking place in dueling press conferences. The group of 13 (male) Senators working on the Senate’s version of the bill has been a lot better about not airing their disagreements loudly in public.

The latest we’re hearing is that Medicaid is a big sticking point. Moderates, such as Ohio Senator Rob Portman, want to see a “less conservative” version of what passed the House. On the other hand, some conservatives, such as Texas Senator Ted Cruz, would like to see deeper cuts to Medicaid by using even more brutal formulas to determine future Medicaid spending growth than what the already pretty draconian House bill contained.

In some ways, I’m glad that they’re thinking carefully about Medicaid, because maybe the Senate will come to realize that the House bill would be one of the single biggest examples ever of the Feds dumping a colossal financial liability onto the states’ laps. Take a look at the chart about halfway down the page of this Vox article. If the per capita cap or block grant rates proposed by the House go into effect, states are going to be on the hook for billions upon billions of dollars.

We’ll be watching out for CBO’s score of the House-passed AHCA next week. We’re hearing Monday or Wednesday.

In other federal news, the Trump Administration announced plans to wind down the SHOP Marketplaces. This was the special program to help small businesses facilitate a choice of health plans for their employees. It never seemed to find its audience: as the WaPo article at the link notes, figures earlier this year showed that it only covers around 230,000 people compared to the 4 million that had been estimated when SHOP launched back in 2014.

Finally, some of you may have seen a bulletin from CMS encouraging states to apply for 1332 “Innovation Waivers” to seek funding for “high risk pools”. Before you panic, a couple of things to know. These aren’t new waivers: 1332 options have been available since the dawn of the ACA. So these have nothing to do with AHCA. And when CMS says “high risk pools” here, it looks like they’re probably referring to our old favorite “invisible high risk pools”, or as we like to call it, “reinsurance” (see previous Coffee CAHC for your in-depth explanation of what that means, if you’ve missed it previously). Our understanding is that these types of waivers were being considered and possibly even encouraged (though perhaps more quietly) under the previous administration, as well.

That said, it’s possible that they mean actual high risk pools – taking high risk individuals out of the general risk pool and putting them in a separate, segregated block – and if that’s the case, I have a hard time believing that any state will be able to credibly make the math work. 1332 waivers can’t impact the federal deficit, and past experiments with high risk pools have almost inevitably been abandoned because the price tag gets astronomical.


State level

The State House is a-bustlin’ right now. Committees are churning through their remaining bills as fast as they can, trying to get everything out of their committee rooms and onto the House and Senate floor. That means last-minute public hearings on last-minute bills, feverish work sessions on things that have already had public hearings, and a whole lotta “carryover”.

We had the public hearing yesterday afternoon on L.D. 1406, which I’ve talked about in the past few Coffee CAHCs. This is the bill that would create more transparency in prescription drug prices here in Maine. We had a strong group of people testify in favor of the bill, and only one representative from the pharmaceutical manufacturers who spoke in opposition. We know there is one other bill seeking a similar solution to the problem of unaffordable prescription drugs still in the pipeline, so we’ll be working this week to get everything squared away to either report out of committee, or get carried over.

Baffled by those terms? Here’s your refresher of the process at work here!

  • A legislator proposes a bill.
  • The “Revisor’s Office” helps write it into legalese and sends it up to the House and Senate.
  • Based on the content of the bill, the House and Senate “reference” (send) it to a committee for consideration.
  • The committee holds a public hearing. This is the chance for members of the public to weigh in on it – for, against, or neither for nor against.
  • Once the public hearing’s over, the committee will have one or more “work sessions”, where they get together as a committee and either vote for or against it as written, or adopt amendments to the bill.
  • Eventually, the committee will make one or more reports: either a unanimous “ought to pass” (OTP) or “ought not to pass” (ONTP) – or, if the bill has been amended, OTP-A/ONTP-A – or you may see a “divided report” when the committee can’t unanimously agree on an action. That might be any crazy permutation you can imagine. A simple version might be a “majority ought to pass” (most people say let’s do it as written) and “minority ought not to pass” (some disagree); or a 6-member OTP, 3-member OTP-A, and 4 member ONTP…etc, etc.
  • That report then gets back to the House and Senate, who will bounce it back and forth through various kinds of action that have interesting names but generally aren’t super important unless you’re a parliamentary process nerd like me or CAHC superfan LH*.
  • Once the House and Senate have agreed on the same action on a matching version of the bill, it either goes to the Governor (if they agreed to pass it) or is dead (if they didn’t agree or agreed to vote it down).
  • Committees have another option, which is to recommend that a bill be “carried over” to the short session. Remember, the legislature meets each year over a two-year biennial term: the “long session” (year 1, January-June) and the “short session” (year 2, January-April). This sometimes happens when the committee wants more time to consider especially big issues, but committees are also limited in how many bills leadership will allow them to carry forward, because the short session is mostly for clean-up, not generally for deep-dive committee work.

While some bills are passed or killed “under the hammer” (that is, by unanimous consent without a debate or floor vote), lots of bills do have more action on the floor. That takes time. And that’s why committees are now scrambling to get everything into the House and Senate.

Meanwhile, the budget continues to be picked away at. Both sides are still posturing that coming to any kind of agreement looks like long odds. Color me skeptical on that front: we hear the same kind of noise every two years. Usually, a deal lands late. But to be honest, after my track record when it comes to political predictions, who knows: stranger things have happened!


*First reading, second reading, engrossed, etc. – and, fun fact, some of these parliamentary “postures” technically get their own legislative committees! Bet you didn’t know there was a Standing Senate Committee on Bills in the Second Reading, didja?**


**OK, if you’re reading Coffee CAHC, you probably DID know that there was a Standing Senate Committee on Bills in the Second Reading and that means you’re a nerd like me and we love ya for it.


Would you like to know more?

Tim Jost takes a look at that CMS update about 1332 waivers.

Health Affairs does a deep-dive on how bad Medicaid “reform” could get for the states.

Here’s a weird one: a slew of Medicaid fraud charges was dismissed by a state judge after it was revealed that workers at DHHS may have forged most of the paperwork on which the charges were based.


Until next time, friends, I remain,


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