It’s amazing the difference a week can make. Last week Rep. Mark Amodei was a “NO” on passage of the American Health Care Act (AHCA), H.R. 1628. I’m not sure what he was offered to buy is “YEA” vote, but it must have been good, for him that is, because it certainly is good for any of us:
Position on April 28, 2017
With health care being at the forefront of our agenda this week in the House, I think it’s important to continue focusing on the salient facts. Following extensive coordination and discussions with Nevada Medicaid officials and House leadership staff about the Medicaid portion of the American Health Care Act (AHCA), I’ve been left with the following conclusions:
- 21% of Nevada’s insured population is insured through Medicaid;
- The national average is 20%.
Based on numbers supplied from Governor Sandoval’s Administration which I believe to be credible, if this bill were to become law, after 48 months, there will be a nearly $240 million funding shortfall for Medicaid in Nevada. Additionally, it does nothing to make the proposed Medicaid reforms (which impact three times that many Nevadans) more workable for Nevada.
It’s no surprise to businesses or taxpayers that the tax climate in Nevada has been challenging over the last several legislative sessions. Therefore, I will not vote for a bill that leaves the 2019 Legislative Session and Nevada’s new Governor with a nearly quarter of a billion dollar loss in funding. My resolve is further strengthened by President Trump’s recent tax proposal which his Administration has expressly said “pays for itself”. I’m wondering why we need to take nearly $1 trillion out of Medicaid nationwide to pay for a “self-funded” tax proposal.
With respect to the private market reforms, I’ve been left with the following conclusions:
- Those who purchase their health insurance on the private market represent 7% of the Nevada insurance market;
- The nationwide average is 7%.
My analysis of the latest revisions to the private market provision of the American Health Care Act is as follows:
- States would be able to submit waivers to Health and Human Services (HHS) on certain Essential Health Benefit (EHB) Requirements. Under this amendment, there is no way to estimate how much premiums would be reduced nationwide because it would be dependent upon which EHB requirements the states choose to waive. Considering the Nevada State Legislature recently passed a bill which reiterated its commitment to essential health benefits as understood under the Affordable Care Act (SB 394), it is unlikely the state would soon waive any EHB requirements making certain that the amendment has no premium impact on Nevada.
My staff and I will continue to evaluate any and all suggestions and changes in regards to the American Health Care Act. It’s important to note that most health care reform issues must be resolved through legislation that requires 60 votes in the Senate and extensive regulatory work by HHS Secretary Tom Price. While I will continue to keep an open mind, if the current plan is the bill that comes to the Floor for a vote – I will not be supporting it.
Position on May 4, 2017
“Since the convening of the 115th Congress four months ago, my office has been conducting extensive research into the various AHCA proposed reforms.
“The notions that healthcare in general, and the seven-year-old Affordable Care Act in particular, needed further legislative action, are in my opinion – valid.
“With Speaker Paul Ryan’s proposal – the AHCA – introduced several months ago, my primary focus in evaluating that proposal was, and remains, the impacts on Nevada’s second largest insurance group – those on Medicaid (21%).
“When speaking on the Medicaid issue, I break Nevadans on Medicaid into two groups. Those on traditional Medicaid: children, pregnant women, disabled, and the elderly. And those Nevada Medicaid enrollees whose eligibility was established through Medicaid expansion and by the Affordable Care Act.
“I am happy to indicate to Nevada traditional Medicaid enrollees, that my review of the current version of the AHCA will make no changes in current enrollee eligibility and will likely increase federal funding to Nevada’s traditional Medicaid program based on Nevada’s historical per capita growth rate, versus the growth rate provided in the bill.
“With respect to Nevada’s expanded Medicaid enrollees, my overriding concern was that the AHCA would leave Nevada with a nearly $245 million shortfall by cutting federal Medicaid funding to the states over the coming four years. So long as that potential deficit was a possibility for Nevada – I was a “no” vote. The prospect of either kicking Nevada Medicaid expansion enrollees off of Medicaid, or forcing the 2019 Legislature to make up a nearly quarter of a billion dollar loss in federal Medicaid funding was, and is not, acceptable to me.
“As a result of extensive discussions, further research, and the involvement of present and former Nevada Medicaid officials, Secretary Tom Price of the U.S. Department of Health and Human Services, Administrator Seema Verma of the Centers for Medicare and Medicaid Services, Vice President Mike Pence, and the House Republican Leadership – I have identified language in the present version of H.R. 1628 which establishes the following facts:
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1. |
“Any Nevadan who has enrolled in the expanded Medicaid program from its inception in 2014 through the end of 2019 is free to remain in the program so long as their income does not exceed 138% of the national poverty level. This is current law under the Affordable Care Act; |
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2. |
“Nevada will continue to receive enhanced federal Medicaid funding for enrollees that it is currently receiving for as long as that enrollee stays in that program; |
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3. |
“Present expanded enrollees lose eligibility only if they exceed income of 138% of the national poverty level, or if they elect to take employer provided or private health insurance; |
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4. |
“Included in the bill are tax credits paid in advance (available even if the individual doesn’t owe taxes) and additional cost-sharing mechanisms to ensure those recently leaving Medicaid can have access to insurance on the private market; |
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5. |
“These conclusions are based on the language contained in the bill, which you may find below. |
Expansion ACA v. AHCA
1. As amended by the ACA, Section 1905(y)(1) of the Social Security Act lists the FMAP rates for the ACA Expansion population:
(NOTE of explanation: Federal Medical Assistance Percentages (FMAP) are the percentage rates used to determine the matching funds rate allocated annually to certain medical and social service programs in the United States of America.)
(y)Increased FMAP for Medical Assistance for Newly Eligible Mandatory Individuals.—
(1) Amount of increase.—Notwithstanding subsection (b), the Federal medical assistance percentage for a State that is one of the 50 States or the District of Columbia, with respect to amounts expended by such State for medical assistance for newly eligible individuals described in subclause (VIII) of section 1902(a)(10)(A)(i), shall be equal to—
(A) 100 percent for calendar quarters in 2014, 2015, and 2016;
(B) 95 percent for calendar quarters in 2017;
(C) 94 percent for calendar quarters in 2018;
(D) 93 percent for calendar quarters in 2019; and 90 percent for calendar quarters in 2020 and each year thereafter.
(E) 90 percent for calendar quarters in 2020 and each year thereafter.
2. AHCA Section 112(b) modifies this section such that this rate only applies to individuals enrolled before 12/31/219 who do not have a break in eligibility for more than one month:
Section 1905 of the Social Security Act (42 U.S.C. 1396d) is amended— (1) in subsection (y)(1), in the matter preceding subparagraph (A), by striking ‘‘with respect to’’ and all that follows through ‘‘shall be’’ and inserting “with respect to amounts expended before January 1, 2020, by such State for medical assistance for newly eligible individuals described in subclause (VIII) of section 1902(a)(10)(A)(i) who are enrolled under the State plan (or a waiver of the plan) before such date and with respect to amounts expended after such date by such State for medical assistance for individuals described in such subclause who were enrolled under such plan (or waiver of such plan) as of December 31, 2019, and who do not have a break in eligibility for medical assistance under such State plan (or waiver) for more than one month after such date, shall be…”
“Accordingly, I have concluded that the potential for Nevada deficits or expanded Medicaid enrollees being kicked off of Medicaid will be avoided. While I know anything to do with American healthcare is incredibly controversial, we need to continue the process of improving healthcare in America. I fully expect the Senate to continue what has been a raucous discussion to say the least. Nevertheless, American healthcare badly needs work. With my vote today, I am supporting a start of that newest work chapter, while attempting to protect Nevadan’s healthcare interests.”
Rep. Amodei’s flip is morally reprehensible and opprobrious.
Rep. Amodei clearly looked at nothing except how the insurance industry might be affected. He did little if anything to explore how passage might impact those Nevadans who have what that same insurance industry calls “pre-existing conditions” and who the insurance industry don’t want to have to insure. Senator Sherrod Brown of Ohio masterfully took to time to detail how that impacts real people:
So what is a pre-existing condition? Let’s put it like this – you may pay more for healthcare under their plan if you’ve been affected by:
AIDS/HIV, acid reflux, acne, ADD, addiction, Alzheimer’s/dementia, anemia, aneurysm, angioplasty, anorexia, anxiety, arrhythmia, arthritis, asthma, atrial fibrillation, autism, bariatric surgery, basal cell carcinoma, bipolar disorder, blood clot, breast cancer, bulimia, bypass surgery, celiac disease, cerebral aneurysm, cerebral embolism, cerebral palsy, cerebral thrombosis, cervical cancer, child-bearing age, colon cancer, colon polyps, congestive heart failure, COPD, Crohn’s disease, cystic fibrosis, DMD, depression, diabetes, disabilities, Down syndrome, eating disorder, enlarged prostate, epilepsy, female, glaucoma, gout, heart disease, heart murmur, heartburn, hemophilia, hepatitis C, herpes, high cholesterol, hypertension, hysterectomy, kidney disease, kidney stones, kidney transplant, leukemia, lung cancer, lupus, lymphoma, mental health issues, migraines, MS (muscular schlerosis), muscular dystrophy, narcolepsy, nasal polyps, obesity, OCD, organ transplant, osteoporosis, pacemaker, panic disorder, paralysis, paraplegia, Parkinson’s disease, pregnancy, restless leg syndrome, schizophrenia, seasonal affective disorder, seizures, sickle cell disease, skin cancer, sleep apnea, sleep disorders, stent, stroke, thyroid issues, tooth disease, tuberculosis, and ulcers. To name a few. And chances are, you or someone you know has dealt with something (or multiple things) on this list.
If this bill were to become law (which hopefully the Senate will prevent), many people with “pre-existing conditions” will become ineligible to participate in the ordinary insurance programs which they’ve been accustomed to purchasing or participating in. They’ll be instead, relegated to “sick people plans” which are called “high risk pools.” Since all the people in those pools will be “sick people” — people who have one or more serious conditions with more expensive drug and treatment costs —premium costs to join such a pool will be much more costly and actual, deliverable benefits will be limited or even rationed.
Rep. Amodei also failed to consider how premium costs will be calculated —> by age. Claiming that the older one gets, the more likely one is to require receipt of benefits for all those premiums you’ve paid over the years. So, once you hit your 50s, the bill allows insurance companies to you FIVE times more for the same policy they sell to a 25 year old. That’s not just going to impact the “individual insurance market” — that’s also going to massively impact the “employer-provided insurance market.” How do you realistically think that’s going to impact an employer’s aging workforce members. One of two things are going to happen. (1) Employers will stop providing insurance altogether (and pocket the money they used to used to subsidize your insurance as their profit without raising your wage/salary a dime. Or (2), they’ll work at making the workplace so hostile for older workers they’ll quit.
Rep. Amodei also didn’t consider that by allowing States to “waiver out” of all kinds of things — like what is covered and whether limits can be placed on deliverable benefits. What that essentially means is that we could see a race to the bottom as some States wishing to capitalize on the employer-provided market could create all kinds of “waivered plans” that make the ‘junk insurance plans” of the pre-ACA years look like premium plans. It’s not inconceivable that we could see plans that don’t cover maternity care, or contraception, or emergency room visits or seriously restricted networks. So when they say … “Hey, don’t worry, you’ll be able to keep your doctor” … Worry!
Then there’s those ACA subsidies that many folks used to be able to purchase insurance. Those have been flattened to limit the Federal Govt’s liability going forward. On the surface, that doesn’t necessarily sound all that bad, but if you make $50K/yr, that flat amount is one thing, but if you make minimum wage or less, say $15K/yr or less that flat-rate subsidy won’t come close to enabling them to purchase healthcare insurance and they’re not going to qualify for Medicaid.
To pay for Medicaid, it requires $200B+. The House GOP allocated a whole romping, stomping $8B in their bill to cover Medicaid. What that means is they’ll be forcing States to “ration” health care and in the process, become death panels by denying healthcare to the sickest of the sick to be able to pay for healthcare for the less sick.
This bill is supposedly a “reconcilliation” bill, which means it MUST be scored by the Congressional Budget Office (CBO) as to it’s costs. The CBO has not yet completed a rescoring of this latest iteration of the bill. Thus, Rep. Amodei voted on a bill for which he had no idea as to it’s costs OR it’s impact on his Nevada constituents.
Lastly, Rep. Amodei ignored the massive tax breaks that will be doled out to those who make well over $200,000/yr. Basically, they’re cutting benefits to older and poor Americans to give BILLIONS of dollars to the rich, making America sicker and putting many in graves prematurely in the process. This bill does absolutely NOTHING to improve healthcare, it’s delivery, or it’s efficacy. It does however, pad the wallets of the rich at our peril.
Oh … and I almost forgot … none of what the GOP alone passed in this bill would apply to members of Congress.
What do you say we terminate Mr. Amodei’s employment in 2018 and see if he can get insurance on his own?
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