By Mark Miller
CHICAGO (Reuters) - The Republicans’ battle to repeal Obamacare is starting to look less like warfare and more like a game of whack-a-mole.
Each time a draconian plan pops up, advocates for healthcare and seniors - and grassroots opponents - grab their mallets and pound them back into their holes. And so it should be with the latest nightmarish repeal and replace plan, Graham-Cassidy.
The plan would slash federal healthcare funding to states by $215 billion through 2026, and more than $4 trillion over a 20-year period, according to Avalere Health, a research and consulting firm. Importantly, Graham-Cassidy’s cuts to Medicaid would decimate our current system of funding for long-term care.
The mallets are already pounding on this one - and that should be no surprise. The Affordable Care Act (ACA) has taken its lumps, but it has gained support as the public comes to realize what is at stake. Sixty percent of the public thinks it is a “good thing” that the last Senate plan failed, and nearly as many (57%) want Republicans and Democrats to work together on improvements to the ACA, according to the latest Kaiser Health Tracking Poll.
The current bill, sponsored by Republican senators Lindsey Graham and Bill Cassidy, would punt the question of healthcare to the states, allowing them to decide on their own plans with support from a federal block grant. The grants would replace the funds currently being used for the ACA’s Medicaid expansion and for subsidies to help people buy insurance via the marketplace exchanges.
Like its predecessor - the Better Care Reconciliation Act (BCRA) - Graham-Cassidy would be a disaster for older Americans, especially those with low incomes. It ends the ACA’s Medicaid expansion, and cuts to the traditional Medicaid program would destabilize access not only to nursing home care but to innovative, fast-growing home and community-based services.
Graham-Cassidy would replace Medicaid’s open-ended federal reimbursement to states with a capped per-beneficiary amount. The initial cap would rise more slowly than the projected growth in per-beneficiary spending states will experience. As federal funding falls behind, states would be left to raise taxes to meet the shortfalls, cut their budgets elsewhere, or provide less Medicaid coverage.
“The cap on the traditional Medicaid program, along with cashiering out the expansion population, will cut overall federal spending by hundreds of billions of dollars,” said Sara Rosenbaum, a professor of Health Law and Policy at George Washington University's Milken Institute School of Public Health.
HAIL MARY PASS
The bill also would end federal funding of retroactive Medicaid eligibility, a key safety-net feature of the program that lets states and healthcare providers cover the cost of care for catastrophically ill people who are eligible but had not been enrolled.
This feature is especially important for older and disabled patients who are not enrolled in Medicaid but experience a sudden catastrophic health problem that generates very large uncovered charges, Rosenbaum notes. This feature allows states to back-date a patient’s eligibility by three months, assuring hospitals and states they will not be left holding the bag for very high healthcare costs.
“It’s like a safety valve on the entire health care system,” she said. Perhaps most stunning, the block grants end entirely after 2026. “At that point, it’s 'Good luck - you’re on your own,'” said Rosenbaum.
Some Republican governors who rejected BCRA have embraced Graham-Cassidy because it would give them greater control of their Medicaid programs. Like BCRA, Graham-Cassidy would let states impose work requirements in the traditional Medicaid program, eliminate coverage for children and adults in need of long-term services and supports or prescription drugs. But research has found these changes would do little more than create barriers to enrollment and coverage retention; most low-income adults already are either working, looking for work, disabled, in school, or caring for a family member.
“The states are enticed by the notion of flexibility,” said Rosenbaum. “They go into it thinking that if only they had more running room they could save money. But this takes away so much federal funding, and then ends it entirely after eight years. It’s hard to imagine what they are thinking.”
The destabilization of nursing home coverage would be especially devastating.
Medicaid covers 62% of long-term care in the United States, according to the Kaiser Family Foundation. A recent Rand Corp report found that 56% of people will spend at least one night in a nursing home when they are between the ages of 57 and 61. People in this age group run a 10% risk of spending three years or more in a nursing home, and a 5% chance of spending more than four years.
The odds of passage for Graham-Cassidy may seem small - Republicans have only until September 30 to pass it without needing 60 Senate votes, and it faces numerous political and procedural hurdles. But Republicans seem as committed as ever to their promise to repeal the ACA.
“On the merits, you have to wonder how this could possibly succeed - it’s even more damaging than what failed this summer,” said Rosenbaum. “It has the feel of a Hail Mary pass - but one never knows with a Hail Mary pass if Mary will get hailed.”
(The writer is a Reuters columnist. The opinions expressed are his own.)