National Academies of Sciences, Engineering, and Medicine: Communities in Action – Pathways to Health Equity

This report from the National Academies of Science, Engineering, and Medicine describes the causes and solutions to health inequities in the United States. This report focuses on what communities can do to promote health equity, what actions are needed by the many and varied stakeholders that are part of communities, as well as the root causes and structural barriers that need to be overcome. Health equity is the state in which everyone has the chance to attain their full health potential and no one is disadvantaged from achieving this potential because of social position or any other defined circumstance. Health equity is inextricably linked with opportunity.

Health disparities are caused not only by fundamental differences in health status across segments of the population, but also because of inequities in factors that impact health status, so-called determinants of health. Only part of an individual’s health status depends on his or her behavior and choice; community-wide problems like poverty, unemployment, poor education, inadequate housing, poor public transportation, interpersonal violence, and decaying neighborhoods also contribute to health inequities, as well as the historic and ongoing interplay of structures, policies, and norms that shape lives. When these factors are not optimal in a community, it does not mean they are intractable: such inequities can be mitigated by social policies that can shape health in powerful ways.

2016.12.09 CommunityEquity

The report is accompanied by a summary of highlights, a compilation of its recommendations, and a social media toolkit.

Posted in Health Status Disparities, Healthy Neighborhoods and Communities, Prevention, Social Determinants of Health | Leave a comment

International Refugee Assistance Project v. Trump: Preliminary Injunction Against Revised Muslim Immigration, Refugee, and Travel Ban

Here is the opinion issued today by U.S. District Court Judge Theodore Chuang explaining his injunction against President Donald Trump’s revised Muslim immigration, refugee, and travel ban.

Among his findings, Judge Chuang concludes that the revised executive order still has an impermissible purpose of discriminating against Muslims:

“…explicit, direct statements of President Trump’s animus towards Muslims and intention to impose a ban on Muslims entering the United States, present a convincing case that the First Executive Order was issued to accomplish, as nearly as possible, President Trump’s promised Muslim ban. In particular, the direct statements by President Trump and Mayor Giuliani’s account of his conversations with President Trump reveal that the plan had been to bar the entry of nationals of predominantly Muslim countries deemed to constitute dangerous territory in order to approximate a Muslim ban without calling it one – precisely the form of the travel ban in the First Executive Order….the history of public statements continues to provide a convincing case that the purpose of the Second Executive Order remains the realization of the long-envisioned Muslim ban. The Trump Administration acknowledged that the core substance of the First Executive Order remained intact….Defendants do not directly contest that this record of public statements reveals a religious motivation for the travel ban….all of the public statements at issue here are fairly attributable to President Trump, the government decisionmaker for the Second Executive Order, because they were made by President Trump himself, whether during the campaign or as President, by White House staff, or by a close campaign advisor who was relaying a conversation he had with the President.”

Judge Chuang, who is a former Deputy General Counsel for the U.S. Department of Homeland Security and a former trial attorney for the U.S. Department of Justice, then rejects any “secular” rationale for the executive order based on national security interests:

“…courts should afford deference to national security and foreign policy judgments of the Executive Branch….The Court thus should not, and will not, second-guess the conclusion that national security interests would be served by the travel ban. The question, however, is not simply whether the Government has identified a secular purpose for the travel ban. If the stated secular purpose is secondary to the religious purpose, the Establishment Clause would be violated….

In this highly unique case, the record provides strong indications that the national security purpose is not the primary purpose for the travel ban. First, the core concept of the travel ban was adopted in the First Executive Order, without the interagency consultation process typically followed on such matters. Notably, the document providing the recommendation of the Attorney General and the Secretary of Homeland Security was issued not before the First Executive Order, but on March 6, 2017, the same day that the Second Executive Order was issued. The fact that the White House took the highly irregular step of first introducing the travel ban without receiving the input and judgment of the relevant national security agencies strongly suggests that the religious purpose was primary, and the national security purpose, even if legitimate, is a secondary post hoc rationale.

Second, the fact that the national security rationale was offered only after courts issued injunctions against the First Executive Order suggests that the religious purpose has been, and remains, primary….

Third, although it is undisputed that there are heightened security risks with the Designated Countries, as reflected in the fact that those who traveled to those countries or were nationals of some of those countries have previously been barred from the Visa Waiver Program….the travel ban represents an unprecedented response. Significantly, during the time period since the Reagan Administration, which includes the immediate aftermath of September 11, 2001, there have been no instances in which the President has invoked his authority…to issue a ban on the entry into the United States of all citizens from more than one country at the same time, much less six nations all at once….The Second Executive Order does not explain specifically why this extraordinary, unprecedented action is the necessary response to the existing risks. But while the travel ban bears no resemblance to any response to a national security risk in recent history, it bears a clear resemblance to the precise action that President Trump described as effectuating his Muslim ban. Thus, it is more likely that the primary purpose of the travel ban was grounded in religion, and even if the Second Executive Order has a national security purpose, it is likely that its primary purpose remains the effectuation of the proposed Muslim ban. Accordingly, there is a likelihood that the travel ban violates the Establishment Clause.

…the Supreme Court has stated that ‘no governmental interest is more compelling than the security of the Nation.’…Defendants, however, have not shown, or even asserted, that national security cannot be maintained without an unprecedented six-country travel ban, a measure that has not been deemed necessary at any other time in recent history. Thus, the balance of the equities and the public interest favor the issuance of an injunction.”

Having served in all three branches of the federal government (he also served as counsel to the House Oversight and Government Reform Committee and the House Energy and Commerce Committee), Judge Chuang also rejects the argument that this presidential action is beyond review by the courts: “Even when exercising their immigration powers, the political branches must choose ‘constitutionally permissible means of implementing that power.’…Thus, although ‘[t]he Executive has broad discretion over the admission and exclusion of aliens,’ that discretion ‘may not transgress constitutional limitations,’ and it is ‘the duty of the courts’ to ‘say where those statutory and constitutional boundaries lie.'”

Judge Chuang concludes: “While Plaintiffs would likely face irreparable harm in the absence of an injunction, Defendants are not directly harmed by a preliminary injunction preventing them from enforcing an Executive Order likely to be found unconstitutional…. Preventing an Establishment Clause violation has significant public benefit beyond the interests of the Plaintiffs. The Supreme Court has recognized the ‘fundamental place held by the Establishment Clause in our constitutional scheme.’… The Founders ‘brought into being our Nation, our Constitution, and our Bill of Rights with its prohibition against any governmental establishment of religion’ because they understood that ‘governmentally established religions and religious persecution go hand in hand.’… When government chooses sides among religions, the ‘inevitable resul’ is ‘hatred, disrespect, and even contempt’ from those who adhere to different beliefs….Thus, to avoid sowing seeds of division in our nation, upholding this fundamental constitutional principle at the core of our Nation’s identity plainly serves a significant public interest.”

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National Center for Health Statistics: Selected Health Conditions Among Native Hawaiian and Pacific Islander Adults: United States, 2014

This is the first data brief reporting results from the 2014 Native Hawaiian and Pacific Islander (NHPI) National Health Interview Survey (NHIS), the first federal survey conducted by the Centers for Disease Control and Prevention’s National Center for Health Statistics (NCHS). Although the Asian or Pacific Islander federal race category was split into two in 1997, few reliable health statistics are available for the NHPI population. In 2014, NCHS fielded a first-of-its-kind federal survey focused exclusively on NHPI population health. This report uses data from that survey, in combination with 2014 data from the annual NHIS, to highlight differences in the prevalence of selected health conditions between the NHPI population and the Asian population with whom they have historically been combined. These results highlight some of the important differences between the NHPI and Asian populations that are obscured when the two groups are combined.

The NHPI NHIS found that NHPI adults were more likely than all U.S. adults to be in fair or poor health, to have diabetes, and to have ever had asthma:

  • The percentage of NHPI adults who were in fair or poor health was 15.5%, which was higher than the percentage among single-race Asian adults (9.2%) and all U.S. adults (12.0%)
  • The percentage of all NHPI adults (4.1%) who had experienced serious psychological distress in the past 30 days was higher than the percentage among single-race Asian adults (1.6%) and higher than, but not significantly different from, the percentage of all U.S. adults (3.1%)
  • A higher percentage of all NHPI adults (5.7%) had cancer compared with single-race Asian adults (3.2%)
  • A higher percentage of all NHPI adults (6.0%) had coronary heart disease compared with single-race Asian adults (3.2%)
  • A higher percentage of all NHPI adults (15.6%) had diabetes compared with single-race Asian adults (8.0%) and all U.S. adults (8.7%).
  • A higher percentage of all NHPI adults (19.2%) had ever been diagnosed with asthma compared with both single-race Asian adults (9.2%) and all U.S. adults (12.8%)
  • A higher percentage of all NHPI adults (9.9%) still had asthma compared with both single-race Asian adults (4.8%) and all U.S. adults (7.4%)
  • A higher percentage of all NHPI adults (28.5%) had lower back pain in the past 3 months compared with single-race Asian adults (17.2%)
  • A higher percentage of all NHPI adults (19.7%) had arthritis compared with single-race Asian adults (11.4%)
  • A higher percentage of all NHPI adults (14.1%) had migraines or severe headaches in the past 3 months compared with single-race Asian adults (9.9%)

Additional detailed public use data from this 2014 NHPI NHIS is available from the NCHS website.

Link to Original Source

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State of Hawaii v. Trump: Temporary Restraining Order Against Revised Muslim Immigration, Refugee, and Travel Ban

U.S. District Court Judge Derrick Kahala Watson has issued a nationwide temporary restraining order against the implementation of President Donald Trump’s revised executive order banning immigration, refugees, and travel from Muslim-majority countries.

The court found: “Because a reasonable, objective observer—enlightened by the specific historical context, contemporaneous public statements, and specific sequence of events leading to its issuance—would conclude that the Executive Order was issued with a purpose to disfavor a particular religion, in spite of its stated, religiously-neutral purpose, the Court finds that Plaintiffs… are likely to succeed on the merits of their Establishment Clause claim…The record before this Court is unique. It includes significant and unrebutted evidence of religious animus driving the promulgation of the Executive Order and its related predecessor.”

The court dismissed President Trump’s argument that the revised executive order was constitutional because it was neutral on its face: “There is nothing ‘veiled’ about [Trump’s] press release…calling for a total and complete shutdown of Muslims entering the United States….Nor is there anything “secret” about the Executive’s motive specific to the issuance of the Executive Order…”

Earlier today, two other federal district courts in Maryland and Washington state also heard similar legal challenges to the revised executive order. As of this posting, those courts have yet to issue any decisions.

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House Budget Committee: Text of American Health Care Act for Markup

Here is the text of the American Health Care Act to be considered for markup by the U.S. House of Representatives Budget Committee this week. This is the consolidated bill after markup and passage last week by the House Energy and Commerce Committee and by the House Ways and Means Committee.  This is the bill that was analyzed by the Congressional Budget Office, which found that by 2026, 24 million more Americans would lose their health insurance under this bill.  The markup, originally scheduled for today, has been postponed to this Thursday, March 16, because of the snowstorm expected in Washington DC today.

Link to Original Source

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Congressional Budget Office: Cost Estimate for American Health Care Act

The Congressional Budget Office (CBO) has published its ten-year (2017-2026) cost estimate for the American Health Care Act (ACHA), the House of Representatives Republican plan to “repeal and replace” the Affordable Care Act (ACA).  The CBO estimates that by 2026, 24 million more Americans will become uninsured under the ACHA, compared to under the current law (the ACA). The number of Americans losing health insurance under the Republican plan would be immediate: 4 million would lose their health insurance this year, and 10 million more would lose their health insurance next year.

By 2026,with the increase in those uninsured under the ACHA, a total of 52 million Americans, or 19% of the U.S. population under age 65, would be uninsured. Today, under the ACA, only 10% of the U.S. population is uninsured. And for Americans with incomes below 200% of the federal poverty level, the percentage of uninsured by 2026 would be over 30%, and close to 40% for those ages 30-49.

Moreover, in the short term, the CBO estimates that average health insurance premiums in the individual health insurance markets (including the health insurance marketplaces created under the ACA) would increase between 15 to 20 percent in 2018-2019. Premiums would especially increase for older Americans because the ACHA allows health plans to charge premiums 5 times higher for older Americans. Overall, the average premiums would then decrease beginning in 2020 as other changes made by the ACHA get implemented and those age 50-64 begin to drop out of the individual market because they are being charged five times the premiums of younger Americans. Meanwhile, the CBO also estimates that out-of-pocket expenses such as responsibility for higher deductibles and co-payments will continue to increase under the ACHA, even for those continuing to pay those higher premiums for maintaining their health insurance. This means that even for those who remain insured, their health care premiums will actually purchase less health care (since they have to pay more for the health care they actually use through these  higher deductibles and co-payments).

The CBO estimates that the federal government would cut its spending on Medicaid by $880 billion over the ten years, resulting in significant cuts to states who now use federal matching dollars to support their Medicaid programs. The CBO concludes that, after the year 2020, when the ACHA changes Medicaid funding into fixed per capita caps (based on Medicaid spending 4 years earlier, in 2016), states would see a minimum annual reduction in Medicaid funding of at least 0.7%. As a result, 14 million Americans who would have been covered by Medicaid under the ACA will lose their health insurance by 2026.

One of the only pieces of good news in the CBO estimate for the Republican sponsors of the bill is that, by repealing the provisions that resulted in increased health insurance coverage, such as premium and cost-sharing subsidies for low-income Americans and the Medicaid expansion, the ACHA is estimated to result in total net federal government savings of $337 billion over the ten years between 2017-2026. However, the way in which those savings are achieved will carry a high price for the lowest income Americans. For example, while the ACHA includes some tax credits to assist in paying for health insurance, the ACHA’s tax credits over the ten years only total $361 billion, compared to the $673 billion that would have been provided under the ACA. In an understatement, the CBO states that the ACHA tax credits “would generally be less generous for those receiving subsidies under current law.” In fact, later in the report, the CBO concludes that the average tax subsidy would be reduced by 40% compared to the ACA. In other words, $312 billion in “savings” (of the total $337 billion in net savings) comes from taking away assistance from the neediest Americans so that they can afford health insurance. As a result, 10 million Americans will lose their coverage.

Moreover, the ACHA also includes massive tax cuts that results from the repeal of $883 billion in taxes on higher income Americans and taxes on health insurance plans, pharmaceutical companies, and medical device manufacturers. $274 billion of those tax cuts only benefit the richest 2% of Americans: $157 billion from repealing the additional 3.8% net investment tax and $117 billion from repealing the 0.9% Medicare tax; both these taxes only applied to single taxpayers earning over $200,000/year, or couples earning over $250,000/year. In addition, under the ACHA, individuals with incomes ABOVE 400 percent of the federal poverty level would receive tax credits that they currently don’t get (or in almost all cases, don’t need, so it is just a tax cut for the wealthiest). All these tax cuts only benefit higher income Americans and these health care industries, not the tens of millions of Americans who will lose their health insurance under the ACHA.

Link to Original Source

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Office of Management and Budget: Request for Additional Comments on Changes to Standards for Federal Data on Race and Ethnicity

The Office of Management and Budget has published a second request for comments about potential changes to the 1997 standards for maintaining, collecting, and presenting federal data on race and ethnicity. Similar to its first request of comments published in September 2016, this request seeks public comments about 1) whether the questions on race (American Indian/Alaska Native, Asian, Black/African American, Native Hawaiian and Other Pacific Islander, or White) and on ethnicity (Hispanic/Latino or not Hispanic/Latino) should be combined; 2) whether there should be a separate category for Middle Eastern and North African individuals; 3) whether these race and ethnicity minimum categories should be disaggregated (and what specific disaggregated categories should be required or encouraged) and 4) changes in terminology about these racial and ethnic categories.

In response its first request for comments, OMB received a total of 3,750 comments, including over 1,200 comments specifically supporting disaggregation of the Asian and the Native Hawaiian and Other Pacific Islander categories, and over 2,200 comments in support of a Middle Eastern and Northern African category.

Based on the recommendations of a federal Federal Interagency Working Group (IWG) for Research on Race and Ethnicity and its analysis of the public comments submitted, OMB has identified specific options for implementing each of these changes and seeks public comments on the identified options.

Comments are due on April 30 and may be submitted online.

Link to Original Source

The IWG report and recommendations also have been published:

Link to Original Source

The IWG also has published a Frequently Asked Questions (FAQs) about this second request for public comments:

Link to Original Source

The IWG itself references this lengthy report from the U.S. Census Bureau on the 2015 National Content Test related to race and ethnicity questions:

Link to Original Source

Posted in Asian American, Native Hawaiian and Pacific Islander Health, Data, Demographic Data, Demographic Data: Race and Ethnicity | Leave a comment

Kaiser Family Foundation: Summary of the American Health Care Act

The Kaiser Family Foundation has published this summary of the American Health Care Act to be considered by the U.S. House of Representatives Ways and Means and Energy and Commerce Committees tomorrow, Wednesday March 8, 2017:

Link to Original Source

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House Republicans Finally Introduce American Health Care Act

On Monday March 7, 2017, nearly 7 years after the enactment of the Patient Protection and Affordable Care Act (ACA), Republicans in the U.S. House of Representatives have finally introduced the first drafts of what they are calling the American Health Care Act (ACHA). There are two first drafts, 57 pages to be considered by the House Ways and Means Committee and 66 pages to be considered by the House Energy and Commerce Committee, with “mark-up” beginning tomorrow morning March 8, less than 48 hours after finally releasing the legislative language. There will be no Congressional Budget Office analysis available so the fiscal impact on the U.S. federal budget and the personal impact on Americans will not be known before the House Committees begin approving the drafts and moving the legislation forward.

There are numerous parts of the two drafts, without any real logical order of topics, and with many different implementation and effective dates, which makes it even more difficult to understand how the legislation would impact health insurance coverage for millions of Americans. Here is some initial analysis, organized by date of implementation. This analysis highlights how long “repealing and replacing” the ACA will take, with many provisions to go into effect beginning in 2018, and most of the important provisions not effective until 2020.

Effective Immediately:

+ Repeal of the individual mandate (requirement to have health insurance coverage) and tax penalties (retroactive to January 2016)

+ Repeal of the employer mandate for large employers (requirement for employers to offer health insurance coverage to their employees) and tax penalties (retroactive to January 2016)

These repeals would make it less likely for employers to offer health insurance to their employees and less likely for individuals to obtain health insurance, especially younger, healthier Americans who otherwise help balance/reduce the costs of those insured; the result is less Americans insured, more costs for health insurance plans so they raise their premiums, which, in turn, makes health insurance less affordable for everyone else. These repeals undo two of the fundamental changes under the ACA that successfully countered the failure of health insurance plans to provide affordable health insurance coverage to Americans on their own.

+ Allows age rating, or variations in health insurance premiums based on age (higher prices for older Americans) up to a ratio of 5:1 (rather than ACA’s limit of 3:1)

+ Repeals the requirement that health plan provide “actuarial value” (premiums reflect estimated costs of care) and allows health plans to offer minimal plans that would only cover catastrophic medical expenses

These provisions allow higher premiums and health plans with less coverage, minimizing the choices of affordable, comprehensive health insurance coverage options. All these provisions will continue to de-stabilize the health insurance markets for individuals, with many unable to afford continued coverage, which in turns means even higher premiums, and less affordable options for those remaining in those markets. While the latter changes allow health plans to charge higher premiums, the continued instability of these markets also will drive some health plans to stop participating in the health insurance exchanges.

Effective Current Fiscal Year 2017 (through September 30, 2017): 

+ Eliminates all Medicaid and health plan funding for Planned Parenthood clinics for one year

This is a blatantly political, mean-spirited attack on Planned Parenthood, which already cannot receive any federal funding for abortion services; this defunds all Planned Parenthood clinics for ALL their health care services – including primary care, cancer screenings, contraception, and other sexual health services – for all their patients covered by Medicaid and any federally-funded health plan.

+ Provides $422 million in funding for community health centers

This is one of the only good things in the bill; without this appropriation, community health centers would have reverted to pre-ACA funding levels; however, this extension of funding is only for the one fiscal year, only postponing this serious cliff of loss of funding. The bill does not address the need for reauthorization and appropriations for the Children’s Health Insurance Program, which also expires in September 2017.

Effective Fiscal Year 2018 (beginning October 1, 2017):

+ Requires redetermination of eligibility for expanded Medicaid every 6 months

Requiring redetermination of eligibility more frequently than annually is a cynical but proven way to drop individuals from coverage; while the number of individuals who are found to be ineligible with more frequent redeterminations are always very small, not meeting the administrative requirements for redetermination in a timely manner (notice of redetermination not received because the individual moved, not responding to requests for updated documentation, etc.) results in loss of eligibility and coverage for many, especially those with lower education and health literacy, and limited English proficiency.

+ Repeals funding of the Prevention and Public Health Fund

This eliminates vital funding for prevention activities that save money in the long term; it also eliminates funding for the Racial and Ethnic Approaches Community Health (REACH) program

+ Creates $100 billion State Innovation Grant and Stability Program (over 9 years, through 2026) to states for high-risk pools, stabilizing private insurance premiums, providing cost-sharing subsidies, promoting preventive, dental, vision, mental health and substance use disorder services, and similar state activities

While this appears at first to be a lot of federal funding, this funding is for state governments (which could essentially keep the funds or give them to health plans) rather than to directly subsidize the costs of health care for Americans; and when divided among 50 states over 9 years, it doesn’t end up being very impactful.

Effective 2018:

+ Repeals tax on health insurance plans

+ Repeals excise tax on medical devices

+ Repeals drug manufacturer fee on branded prescription drugs

+ Repeals 10% sales tax on indoor tanning services

+ Repeals 0.9% Medicare Hospital Insurance payroll tax on high income individuals (income over $200,000; over $250,000 for joint filers)

+ Repeals 3.8% Medicare tax on unearned income for high income individuals (income over $200,000; over $250,000 for joint filers)

+ Repeals $500,000 limit of “ordinary and necessary” business expense deductions for compensation paid to health insurance officers, directors, and executive employees

+ Reduces minimum amount of medical expenses for tax deduction from 10% to 7.5% of the taxpayer’s adjusted gross income

These sections repeal most of the major revenue sources used to fund the ACA; without any analysis from the Congressional Budget Office, it is unknown how the American Health Care Act would be paid for, and what impact it will have on the federal deficit. Many of these repeals only benefit higher income taxpayers.

+ Creates a 30% premium penalty for individuals who have had a lapse in health insurance coverage (63 days or longer) to re-enroll in any coverage

Although the 30% premium penalty sounds high, this will actually create an perverse incentive for healthier Americans to wait until they need health care before enrolling; at that point, the one-time 30% penalty would often be less than the actual costs of health care; so rather than having a stable health insurance market where more Americans are covered and health plans have predictability about their costs, there will be these unpredictable re-entries into the health insurance market that will be costly and disruptive for both individuals and health plans.

+ Increases contribution limit for Health Savings Accounts (HSAs) to $6,550 for individuals and $13,100 for families (plus an additional $1,000 for individuals age 55 and over) to pay for costs of high deductible health plans

+ Eliminates limit of $2,500 on contributions to Flexible Savings Accounts

HSAs are only useful if an individual/family has sufficient income to “save” these amounts, to be used for deductibles, co-payments, and health-related costs such as over-the-counter medications; while these HSA contributions receive favorable tax treatment, they don’t help lower income families who don’t have the disposable income to save these amounts and use the savings for “excess” health care costs not covered by health insurance.

+ Restores Medicaid Disproportionate Share Hospital payments for states that did NOT expand Medicaid

+ Provides $10 billion (over five years, through 2022)  to states that did NOT expand Medicaid for their “safety net providers”

These provisions are concessions to the states that did not expand Medicaid, providing federal funding that otherwise would have supported health insurance coverage for uninsured Americans; however, these funds go to health care providers rather than to uninsured Americans; in fact, non-expansion states lose this funding if they choose to actually reduce the number of uninsured residents in their state by now deciding to implement expanded Medicaid.

+ Prohibits small employer tax credits from being used to pay for coverage from any health plan that provides coverage for abortion services

This is another mean-spirited restriction intended to narrow the number of health plans that provide coverage for abortion services.

Effective 2020:

+ Repeals tax credits for cost-sharing expenses (deductibles and co-payments)

The House Republicans are currently litigating whether these cost-sharing subsidies were appropriated for this current fiscal year 2017; by delaying the repeal of these tax credits until 2020, the House Republicans are now essentially conceding that they will have to appropriate funding for these subsidies until then.

+ Repeals tax credits for small employers who offer health insurance to their employees

+ Implements substitute tax credits to help pay for health insurance premiums, based on age; would only be $2,000/year for those up to age 29, and up to $4,000 for those age 60 and older (up to $14,000 for a family); these tax credits are phased down at an income of $75,000 ($150,000 for joint filers), and phased out to zero at an income of $115,000; tax credits may be used to pay for unsubsidized COBRA coverage; limits tax credits to U.S. citizens, nationals, and “qualified aliens” as defined by the Personal Responsibility and Work Opportunity Reconciliation Act of 1996

The replacement tax credits are far less than the tax credits for premiums and cost-sharing now available under the ACA (for example, with a annual income of $20,000, a 27-year old would only get $2,000 in tax credits under the ACHA, compared to $3,225 under the ACA, and a 60-year old would only get $4,000 rather than $9,900 under the ACA). In addition, minimizing the tax credits for younger, healthier Americans disincentivizes them from buying health insurance. The new restrictions based on immigration status means that many individuals who are legally authorized to reside in the U.S. (for example, migrants from the Compact of Free Association jurisdictions in the Pacific Islands) would no longer be able to obtain tax credits to help them buy affordable health insurance.

+ Repeals federal funding for Medicaid expansion (preserves a lower level of federal funding for individuals enrolled in expanded Medicaid as of December 31, 2019)

+ Repeals guaranteed federal funding for Medicaid, freezes total federal funding for Medicaid, and replaces federal funding to states with a per capita cap based on federal funding provided to each state (using five Medicaid population categories of elderly, blind and disabled, children, adults without ACA expansion, and adults under ACA expansion) as of 2016 (plus minor adjustment for inflation)

+ Repeals the requirement to provide “essential health benefits”, or a minimum level of health care services, in Medicaid

+ Repeals presumptive eligibility for Medicaid (requires documentation and verification  of eligibility before coverage begins)

These fundamental changes to how Medicaid is funded are the most significant and damaging parts of the bill; once the per capita caps are implemented and overall Medicaid funding frozen, there will be less federal funding available to the states, which will force the states to restrict eligibility, pay providers less, and offer less benefits. That in turn will result in hundreds of millions of dollars of cost-shifts to the states (who would have to use state funds to backfill some of the federal funding cuts), health care providers (who would be paid less), and Medicaid beneficiaries (who would have to begin to pay premiums, deductibles, and co-payments, all for less health care benefits).

+ Restores Medicaid Disproportionate Share Hospital payments in expansion Medicaid states

+ Suspends 40% excise tax (“Cadillac” tax) on high-cost health plans provided by employers from 2020 through 2024

The American Health Care Act does not repeal or replace the following parts of the Affordable Care Act:

+ health insurance marketplaces offer health insurance; health plans in such marketplaces must cover pre-existing conditions, must guarantee coverage and renewal, must cover adult children up to age 26, caps on out-of-pocket expenses, no annual or lifetime limits on coverage, must provide “essential health benefits”, must meet minimum “medical loss ratio” (limit on administrative expenses/profits)

+ prohibitions against discrimination based on age, sex, race, ethnicity, national origin, or disability

+ states can offer a Basic Health Program (currently offered by New York and Minnesota)

+ states can continue to apply for an ACA section 1332 waiver to implement other innovations as long as they are cost-neutral

+ all quality improvement and payment reform initiatives, including funding and authority of Centers for Medicare and Medicaid Services’ Center for Medicare and Medicaid Innovation and Independent Payment Advisory Board

There also are no changes to the Medicare program although the repeal of several of the Medicare taxes significantly threatens the financial stability of the Medicare program in the future.

Finally, despite campaign pledges and other rhetoric, there are no provisions in the current drafts about more generous “risk corridor” payments to health plans (that end up with more high cost members than anticipated) and the ability of health plans to selling health insurance across state lines (which would result in a “race to the bottom” to avoid state regulations that protect consumers). While the selling across state lines provision could still be added later or introduced as a separate bill, it may have been thought to be outside the scope of the budget reconciliation process being used to enact this American Health Care Act, which is limited to tax revenues, tax credits, and federal government expenditures.

Here is the draft to be marked up by the House Ways and Means Committee:

Link to Original Source

The Ways and Means Committee has prepared a section-by-section summary:

Link to Original Source

And here is the draft to be marked up by the Energy and Commerce Committee:

Link to Original Source

The Energy and Commerce Committee has prepared this section-by-section summary:

Link to Original Source

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Republican Policy Brief: Obamacare Repeal and Replace

Here is the policy brief released today by House and Senate Republicans on how to “repeal and replace Obamacare”, or the Affordable Care Act (ACA). The plan repeats the promises made by President Donald Trump and Republican Congressional leadership to achieve the following: “Lowers costs, expands access, improves quality, and puts patients and families in charge of their care, while protecting patients with pre-existing conditions and ensuring dependents up to age 26 can stay on their parents’ insurance.” It references House Speaker Paul Ryan “A Better Way” proposal rather than just-confirmed Health and Human Services Secretary Tom Price’s Empowering Patients First Act.

The plan concedes that millions of Americans need federal government support to make health care accessible and affordable, both through health insurance markets and the Medicaid program. While repealing the ACA’s premium and cost-sharing subsidies through federal tax credits, the plan creates a new national, refundable, federal tax credit  for all Americans, that increases with age. However, the plan fails to specify how much the credits will be, and whether they will be sufficient to make health insurance affordable. By de-linking such tax credits from income and from the actual cost of health insurance, it is likely that they, in fact, will be insufficient to make health insurance affordable for those who need it the most, i.e. low-income Americans, and those living in geographic areas where the cost-of-living, and the cost of health insurance, is higher.

The plan notes that this new tax credit will be paid for by repealing most of the ACA taxes (on health plans, medical devices, and prescription drugs) as well as the tax penalties on employers and individuals for not offering or purchasing insurance under the ACA.

The plan also expands the availability of tax-deductible health savings accounts (HSAs), which only are useful to individuals and families with higher incomes that have income to deduct. By nearly doubling the amount that could be deducted for such HSAs, the plan provides a massive tax cut to higher income Americans.

The plan also cynically repeals the expansion of Medicaid to all low-income Americans with double-speak language about giving control of Medicaid back to states. Repealing the Medicaid expansion means cutting off federal funding for the expansion of Medicaid in 31 states and the District of Columbia so that those states would have to fund health insurance coverage with state dollars, or cut off coverage for hundreds of thousands of residents in their states. The plan states that there will be a transition period before these federal funds are cut off but does not specify how long that will be.

The plan also allows states to reestablish high risk pools for those with pre-existing and chronic conditions that are the most expensive to insure; such high risk pools failed to provide affordable coverage when states offered them prior to the ACA. The plan does not specify what level of federal funding, if any, will be provided to support these multi-billion dollar high risk pools.

Then the plan goes far beyond “repealing” the ACA and includes a fundamental change to how Medicaid is funded, from a shared responsibility (and governing rules) between federal and state governments to either a “per capita allotment” (or cap) or block grant that will result in dramatic cuts in federal funding to the states, resulting in cost shifts to states, health providers, and Medicaid beneficiaries. Under the per capita cap, different levels of federal funding would be available for aged, blind and disabled, for children, and for adults but the amounts would be fixed based on the past number of beneficiaries rather than actual need. Since Medicaid is program subject to counter-cyclical economic forces, this always means that there will be less federal funding available when it is most needed, i.e. when the economy is in a downturn and there are more who are unemployed and uninsured.

States also will have the option of choosing a block grant funding formula for Medicaid rather than per capita caps, again based on the past level of funding. It is not clear whether that would include the funding for expanded Medicaid since the plan states that the block grant funding formula “would assume that states transition individuals currently enrolled in the Medicaid expansion out of the expansion population into other coverage”; it’s not clear what options states would have to cover the Medicaid expansion population without federal funding.

The one concession that seems to have been made to the 10 states with Republican governors that expanded Medicaid is the restoration of Disproportionate Share Hospital payments; under the ACA, these payments to hospitals for uncompensated care were reduced because Medicaid provided health insurance coverage for those formerly uninsured patients. While this restoration financially helps hospitals in those states, it doesn’t actually provide for health care for those who will be cut off for expanded Medicaid programs.

House Speaker Paul Ryan said today that legislation implementing this plan will be introduced next week, after Congress returns from a President’s Day long weekend.

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