Last week offered a range of possible directions on health care in 2017:  move toward a short-term fix of the ACA, repeal it and replace it with block grants or re-ignite the battles over universal care:

HELP COMMITTEE ACTION

The HELP Committee held two more hearings on Tuesday, September 12, and on Thursday, September 14.  These hearings once again focused a great deal of attention on the need to fund the CSRs, Cost-Sharing Reductions, greater flexibility in the current waiver process and as Senator Lamar Alexander (R-TN) suggested, expand the availability of “copper” or catastrophic plans.

The Tuesday hearing focused most of the testimony on the waiver process.  There are likely some bipartisan ideas such as placing a time limit on HHS in their approval process.  There also seemed to be a consensus on allowing “copy-cat” waivers that would allow one state to copy another state’s proposal and adjusting the current cost neutrality requirement to apply across both Medicaid and the ACA.  One challenge remains how the essential benefits plan would be effected and other consumer protections might be effected.  Chairman Alexander said he did not want to weaken consumer protections.  Senator Patty Murray (D-WA). Ranking Member, did caution that some testimony she heard would threaten certain coverage such as access to substance use, mental health and maternal health coverage but she also sounded positive about reaching an agreement.

Chairman Lamar Alexander (R-TN) said he hoped to reach a deal early this week.

FINANCE COMMITTEE ACTION

While Alexander was leading an effort for a short-term fix on a bipartisan basis, other soundings around the Capitol were not as positive.  Also on Tuesday, the Senate Finance Committee was holding a hearing on the ACA.  The opening remarks of Chairman Orrin Hatch (R-UT) sounded a more negative tone,

“I am concerned that many of the proposals for a bipartisan solution would amount to little more than a bailout of the current system. This, in my view, would be a mistake.” 

He went on to criticize the ACA, “Obama Care” and discussed costs and expenses.  The Senate Finance Committee has jurisdiction over Medicare, Medicaid (and any technical fix to expanded Medicaid coverage to youth formerly in foster care) and tax policy.  While the HELP Committee actions would be limited to that committee’s jurisdiction, the opinion of Chairman Hatch could be a major roadblock to a bipartisan deal.

The Finance Committee would also be the avenue to fix the current problem with the ACA provision that requires Medicaid coverage for youth formerly in foster care up to age 26.  The problem is that the provision only requires the protection in the state the young person resided while in foster care. Only 14 states have taken the option to extend Medicaid to these young people if they have moved to their state.

Senator Bob Casey (D-PA) introduced a bill on Thursday to address what was really a technical shortfall, the Health Insurance for Foster Youth Act (S. 1797). This bill ensures that youth who age out of foster care, or leave foster care for a kinship placement, have Medicaid coverage no matter which state they aged out in.  The bill also expands coverage for youth who left care at age 14 to be in kinship placement and requires state Medicaid programs to work with child with child welfare agencies to establish outreach and enrollment programs so more youth who are transitioning out of foster care can have health insurance.  But such a fix is unlikely in a HELP bill unless Senator Hatch pushes it.

REPEAL AND REPLACE

While these hearings were taking place, two other new bills were released.  The first was the unveiling of the Graham-Cassidy bill.  Senator Lindsey Graham (R-SC) and Senator Bill Cassidy (R-LA) bill would create a temporary ten-year block grant of the Medicaid funding that is provided to state that have taken the Medicaid expansion.  They would add to that other funds now flowing into the ACA.  States would get these funds to wrap around various health care coverage.  In addition to this block grant the bill would include the Medicaid cap proposal in the previous Senate and House versions of a repeal bill.  Families USA has issued an analysis of the Graham-Cassidy legislation.

By this past weekend, there were growing signals this final repeal may be picking up traction.  Senator Cassidy has been working hard to get another vote.  The Graham-Cassidy bill is operating on a limited time-frame itself.  On September 30, the reconciliation instruction that allows the Senate to approve a repeal bill runs out.  The White House and House are still pushing for another repeal vote.  While the debate time on a reconciliation tool ran out when the Senate last voted on the reconciliation back in August, leadership could still bring up the Graham-Cassidy bill and vote on it.  Cassidy says he has 49 votes but that may not be clear yet.

The Congressional Budget Office (CBO) must score the bill to determine, cost, savings and impact on health insurance coverage.  They have been directed by Senate leadership to speed up the review.  Another factor is that this vote would be for real.  The last vote the Senate took and failed on with 49 Republican votes were cast with a view by some Senators that they were voting for a “skinny” bill that would be further refined.  If the Cassidy-Graham bill passed the Senate the House would likely pass it.  This has advocates concerned and there may be another ramp up to campaign against the legislation.  The vote would likely happen after the short Rosh Hashanah break.

SINGLE PAYER CAMPAIGN

While this was happening Senator Bernie Sanders (I-VT) was unveiling his Medicare for All Act that would expand Medicare to all people.  It would expand Medicare to all health care, prescription drug coverage, dental care, optical care without deductibles or co-pays. While the bill does not attach actual funding mechanisms there was separate document suggesting various tax increase including a new 7.5 percent employer tax, 4 percent consumer payroll tax and several other tax code changes that could or would be added.

The single payer proposal has the cosponsorship of 15 other Senate Democrats and has no chance for passage in this Congress.  If it were to come up in a future Congress look for deeper dive into costs and tax methods to cover that cost and setting health care reimbursements as well as repeats from the debates of 1993-94 and 2009-10 to come back: death panels, health care rationing, waiting lists, job loss, and “not wanting the government to be involved with my Medicare,” as well as the debate on taxes