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.

Link to Original Source 

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Center on Budget and Policy Priorities: Trump Health Rule Would Reduce Tax Credits, Raise Costs, For Millions of Moderate-Income Families

This policy brief from the Center on Budget and Policy Priorities analyzes the proposed rule misleadingly named as “market stabilization” released yesterday. The proposed rule would raise premiums, out-of-pocket costs, or both, for millions of moderate-income families. If finalized as proposed, the rule would reduce the amount of health care that marketplace plans have to cover. That would allow insurers to offer plans with higher deductibles and other out-of-pocket costs than they can now sell through the marketplaces. It would also have the hidden impact of reducing the Affordable Care Act’s (ACA) premium tax credits, which help moderate-income marketplace consumers afford health care. As a result, the rule would leave millions of families with higher premiums and worse coverage. Comments on the proposed rule are due on March 7, 2017.

Link to Original Source

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Centers for Medicare and Medicaid Services: Proposed Rule for ACA “Market Stabilization”

In stunning governmental doublespeak, the Centers for Medicare and Medicaid Services (CMS) has issued this proposed rule misleadingly named “marketplace stabilization” that will severely narrow access the health insurance marketplaces created by the Affordable Care Act (ACA), and reduce costs (and increase the profit margins) for health insurance plans. To add insult to injury, this proposed rule, yet to be published in the Federal Register, only allows less than three weeks for public comments, rather than the usual minimum comment period of 30 days. Comments are due March 7, 2017.

According to CMS, here are the key elements of the proposed rule:

  • Special Enrollment Period Pre-Enrollment Verification: The rule proposes to expand pre-enrollment verification of eligibility to individuals who newly enroll through special enrollment periods in Marketplaces using the platform. This proposed change would help make sure that special enrollment periods are available to all who are eligible for them, but will require individuals to submit supporting documentation, a common practice in the employer health insurance market. This will help place downward pressure on premiums, curb abuses, and encourage year-round enrollment.
  • Guaranteed Availability: The rule proposes to address potential abuses by allowing an issuer to collect premiums for prior unpaid coverage, before enrolling a patient in the next year’s plan with the same issuer. This will incentivize patients to avoid coverage lapses.
  • Determining the Level of Coverage: The rule proposes to make adjustments to the de minimis range used for determining the level of coverage by providing greater flexibility to issuers to provide patients with more coverage options.
  • Network Adequacy: The proposed rule takes an important step in reaffirming the traditional role of states to serve their populations. In the review of qualified health plans, CMS proposes to defer to the states’ reviews in states with the authority and means to assess issuer network adequacy. States are best positioned to ensure their residents have access to high quality care networks.
  • Qualified Health Plan (QHP) Certification Calendar: In the rule, CMS announces its intention to release a revised proposed timeline for the QHP certification and rate review process for plan year 2018. The revised timeline would provide issuers with additional time to implement proposed changes that are finalized prior to the 2018 coverage year. These changes will give issuers flexibility to incorporate benefit changes and maximize the number of coverage options available to patients.
  • Open Enrollment Period: The rule also proposes to shorten the upcoming annual open enrollment period for the individual market. For the 2018 coverage year, we propose an open enrollment period of November 1, 2017, to December 15, 2017. This proposed change will align the Marketplaces with the Employer-Sponsored Insurance Market and Medicare, and help lower prices for Americans by reducing adverse selection.

In fact, the new documentation requirements for Special Enrollment Periods are intended to keep Americans out of the health insurance marketplaces by placing new administrative barriers in the way of their enrollment; yet the CMS press release uses the phrase “expand” to make it sound like this is an expansion of coverage. CMS estimates that these new documentation requirements will be required for up to 650,000 enrollees.

CMS uses the heading “Guaranteed Availability” to describe new barriers to continued coverage for individuals who have missed premium payments; this doesn’t “guarantee” availability of coverage, it cuts coverage off. This provision is consistent with the Indiana Medicaid expansion waiver drafted by CMS-nominee Seema Verma and then Governor Mike Pence that allows Indiana to cut Medicaid beneficiaries off from eligibility for missed premium payments.

Similarly, while the heading is “Open Enrollment Period”, the proposed rule change is to cut in half the time period for individuals to enroll for health insurance next coverage year (2018). By giving less time for enrollments, enrollments will decline.

And rather than providing affordable, accessible coverage, the proposed rule instead gives “greater flexibility” to health plans to offer narrower, less health insurance coverage under the ACA’s complex metal tier system  (using the Latin “de minimus” to cover up that this means less, not more coverage).

The proposed rule also narrows the ACA rules for ensuring that there are sufficient providers in health plan networks to actually provide care to those enrolled. By loosening the “network adequacy” rules to only require that 20% rather than 30% of providers be  “essential community providers” and to expand the list of who is considered an essential community provider, the proposed rule makes those networks potentially inadequate, meaning that those with marketplace coverage may not actually have access to sufficient numbers of providers.

And finally, the proposed rule declares CMS’ intention to delay the deadline for submissions by health plans who want to offer coverage through the health insurance marketplaces in 2018, without specifying any new timelines. The first deadline for coverage year 2017 was April 4, 2016. As it still is uncertain whether the Republican-majority Congress and President Trump can reach agreement on how to de-fund or repeal the ACA, the process for continuing the health insurance marketplaces needs to move forward. By announcing that the deadlines will change but not when, less than two months from the first deadline, only adds to the uncertainty and instability.

In its cost analysis, CMS concedes: “changes such as shortened open enrollment period, pre-enrollment verification for special enrollment periods, reduced actuarial value of plans, less expansive provider networks [would] result in lower enrollment, especially for younger, healthier adults” and “would tend to increase premiums”, which also will result in lower enrollments. These changes will only reduce enrollment and de-stabilize the health insurance markets, not stabilize them.

Curiously, the proposed rule does not reference President Donald Trump’s Executive Order 13765 on the ACA but does reference Executive Order 13771 requiring the repeal of two regulations for every new regulation. The proposed rule is exempt from the latter because it reduces, not increases, costs to the federal government. The only way the proposed rule decreases costs is by decreasing enrollment, again highlighting how the rule will de-stabilize the health insurance markets rather than stabilizing them.

Link to Original Source

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Breaking News: Richard Bresser Named as President/CEO of Robert Wood Johnson Foundation

The Robert Wood Johnson Foundation has named Richard Bresser, MD, as its next President/CEO. Dr. Bresser currently is the chief health and medical editor for ABC News and a former acting director for the Centers for Disease Control and Prevention (CDC). Among the top stories he covered as a pediatrician and infectious disease specialist was the Ebola epidemic, beginning with reporting from Uganda in 2012. At the CDC, he was the director of the Coordinating Office for Terrorism Preparedness and Emergency Response.

Dr. Besser received his Bachelor of Arts degree in economics from Williams College and medical degree from the University of Pennsylvania. He completed a residency and chief residency in pediatrics at John Hopkins University Hospital in Baltimore. Dr. Besser began his career at the CDC in 1991 in the Epidemic Intelligence Service working on the epidemiology of food-borne diseases. He served for five years on the faculty of the University of California, San Diego as the pediatric residency director, while working for the county health department on the control of pediatric tuberculosis. He returned to CDC in 1998 as an infectious disease epidemiologist working on pneumonia, antibiotic resistance and the control of antibiotic overuse.

He volunteers as a pediatrician with the Children’s Aid Society in New York City, and he is currently a Professor of Pediatrics at Columbia University and a Distinguished Visiting Fellow at the Harvard School of Public Health.

Dr. Besser will succeed Risa Lavizzo-Mourey, MD, who has led the foundation for the last 14 years. He will assume leadership of the $10 billion foundation this April.

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University of California Berkeley Labor Center: California’s Projected Economic Losses Under ACA Repeal

This research brief from the University of California Berkeley Center for Labor Research and Education estimates the economic losses in California from a repeal or re-funding of the key sections of the Affordable Care Act (ACA). An estimated 3.7 million Californians enrolled in expanded Medicaid (MediCal) would lose that coverage, and another 1.2 million individuals enrolled through California’s state health insurance marketplace, Covered California, would lose federal subsidies to make private health insurance more affordable. These two sections of the ACA have been the largest drivers of the historic reduction in California’s uninsured rate from 17.2% in 2013 to 8.6% in 2015.

California would lose approximately $20.5 billion in annual federal funding for the Medi-Cal expansion and Covered California subsidies. The economic losses associated with these lost federal dollars would be partially offset by limited economic gains from other provisions that may be included as part of the repeal of the ACA, which could yield $6.3 billion in tax cuts to California insurers and high-income households and nearly $1.3 billion in eliminated penalties for uninsured individuals and employers not offering affordable coverage.

The reduction in federal health insurance funding would lead to the loss of approximately 250,000 jobs in California, which would be slightly offset by the addition of 20,000 jobs due to the tax cuts for high-income households, 11,000 jobs due to the elimination of the fee on insurers, 8,000 due to the elimination of the penalty for large employers not offering affordable coverage, and 2,000 jobs due to the elimination of the penalty for the uninsured. The net effect of partial ACA repeal would be the loss of 209,000 jobs in California.

The majority (135,000) of these lost jobs would be in the healthcare industry, including at hospitals, doctor offices, labs, outpatient and ambulatory care centers, nursing homes, dentist offices, other healthcare settings, and insurers. But jobs would also be lost in other industries. Suppliers of the healthcare industry, such as food service, janitorial, and accounting firms, would experience reduced demand, leading to job loss.  Some California counties would be especially adversely affected by partial ACA repeal because they have a higher-than-average share of their population enrolled in the MediCal expansion. For example, there would be 63,000 jobs lost in Los Angeles County; 12,000 jobs lost in San Bernardino County; 6,000 jobs lost in Fresno County; and 5,000 jobs lost in Kern County.

The state also would lose an estimated $1.5 billion in state and local tax revenue from the partial repeal of the ACA. Federal funding for MediCal and Covered California subsidies supports jobs in the healthcare industry and at healthcare suppliers, and the income that these workers spend locally supports jobs in a variety of industries. The Californians who hold these healthcare, restaurant, insurance broker, and other jobs pay state income and sales taxes. The federal spending also increases the state’s corporate profit tax revenues, along with some other smaller taxes and fees.

Finally, there is an overall economic multiplier effect from these massive changes in health insurance coverage, tax revenues, and job losses.  The combination of the direct effect on the healthcare industry, the indirect effect on suppliers, the induced effect of reduced spending by affected healthcare workers in their communities, and the induced effect of increased spending by individuals affected by the tax cuts and elimination of penalties would result in a total loss of more than $20.3 billion in GDP throughout the state.

This analysis was conducted using national level Congressional Budget Office estimates, applied to California, using economic data from IMPLAN Online 2015. Some of the provisions that would be included under ACA repeal would be eliminated immediately, while the effective date for other provisions would be delayed. For simplicity, the effects are modeled as if they all take place in 2017, and results are presented in 2017 dollars.

Funding for the research brief was provided by The California Endowment.

Link to Original Source

The Labor Center also has prepared fact sheets describing these economic impacts for the 14 California counties most impacted.

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Commonwealth Fund: Repealing Federal Health Reform – Economic and Employment Consequences for States

This issue brief from the George Washington University Miliken Institute School of Public Health describes the economic and employment impact of repealing or de-funding the key sections of the Affordable Care Act (ACA). Based on economic modeling, it is estimated that repealing the ACA would result in a $140 billion loss in federal funding for health care in 2019, leading to the loss of 2.6 million jobs (mostly in the private sector) that year across all states. A third of lost jobs are in health care, with the majority in other industries. If adequate replacement policies to at least maintain the number of those insured through the ACA are not in place, there will be a cumulative $1.5 trillion loss in gross state products and a $2.6 trillion reduction in business output from 2019 to 2023. State government budgets and health care providers will be particularly hard hit by the funding cuts. The issue brief was funded by The Commonwealth Fund.

Link to Original Source

Here is the appendix detailing the estimated loss of jobs and loss of federal funding for each state and the District of Columbia:

Link to Original Source

Fact sheets describing these economic and employment consequences for each state also are available.


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National Immigration Law Center: Federal Guidance on Public Charge

With President Donald Trump’s executive orders on immigration law and policy issued earlier this week, many immigrants, as well as health and human service providers, are gravely concerned about renewed attacks on immigrant eligibility for public benefits. One of Trump’s executive orders includes the prioritization of enforcement activities against immigrants who “have abused any program related to receipt of public benefits.”

However, the only legal authority to either deport or deny immigration status is the federal law that excludes immigrants who are determined to be a “public charge” (section 212(a)(4)) of the Immigration and Nationality Act).  Administrative immigration courts, as well as administrative guidance from the Department of Homeland Security issued in 1999,  have interpreted this exclusion to apply only to immigrants who are receiving cash benefits from public programs as their sole or primary source of income, such as Supplemental Security Income (which usually means the individual has a long-term disability, which is also evidence of one’s inability to financially support themselves),  Temporary Assistance for Needy Families, or local government General Assistance; and to immigrants who are institutionalized in long-term care at government expense. There must be a case-by-case determination that the immigrant is not able to financially support himself or herself, with consideration of the totality of the circumstances. An immigrant can show a change in circumstances, or future sources of financial support from family members or others through affidavits of support to avoid a public charge determination.

Under these long-standing interpretations, receipt or use of health care insurance (including Medicaid, Children’s Health Insurance Program, and health insurance purchased through a health insurance marketplace, including receiving premium or cost-sharing tax credits), health care services, health clinics, prenatal care, emergency care, nutrition programs (including the Supplemental Nutrition Assistance Program (SNAP), Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), National School Lunch and School Breakfast Program), educational assistance (including Head State and financial aid), child care services, foster care and adoption assistance, job training programs, unemployment benefits, housing benefits, energy assistance, emergency disaster relief, and many other types of public assistance have never been considered in public charge determinations. Moreover, in practice, the public charge determination has only been used when an immigrant is first seeking admission to the U.S., applies for lawful permanent residence, or seeks to re-enter the U.S. after a long absence out of the country. It almost has never been used as a basis of detention or deportation.

So while the Trump executive order prioritizes enforcement actions based on “abuse of any program related to public benefits”, there is no basis in current immigration law for such enforcement actions. While the Department of Homeland Security could withdraw or change its 1996 administrative guidance, it would still be bound by the decades of administrative interpretation and the historical practice of applying the public charge exclusion, and could not unilaterally re-interpret the law. Of course, Congress could also amend the underlying immigration statute itself, but that would require actual legislation, not simply an executive order or executive re-interpretation of the law.

This issue brief from the National Immigration Law Center describes the public charge exclusion in detail, including the 1999 administrative guidance.

Link to Original Source

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Executive Order: Enhancing Public Safety in the Interior of the United States

This executive order issued by President Donald Trump focuses on immigration law enforcement activities in the interior, non-border areas of the United States, and has the purpose to “direct executive departments and agencies to employ all lawful means to enforce the immigration laws of the United States.” In prefatory statements that sound more like campaign rhetoric rather than statements of federal government policy, the executive order also states: “[m]any aliens who illegally enter the United States and those who overstay or otherwise violate the terms of their visas present a significant threat to national security and public safety.”

Much of the executive order is focused on facilitating federal immigration law enforcement activities with state and local governments: “[a]lthough Federal immigration law provides a framework for Federal-State partnerships in enforcing our immigration laws to ensure the removal of aliens who have no right to be in the United States, the Federal Government has failed to discharge this basic sovereign responsibility.” Section 2(c) states that it is now that policy of the executive branch to “[e]nsure that jurisdictions that fail to comply with applicable Federal law do not receive Federal funds, except as mandated by law.” On its face, this is simply stating the obvious, that state and local jurisdictions must comply with any conditions for receiving federal funding that are established in federal laws authorizing and appropriating that funding (for example, following eligibility and benefit rules to provide a Medicaid program with federal funding). However, this executive order could be interpreted much more broadly, conditioning ANY federal funding with compliance with ALL federal laws, and the executive branch’s interpretation of those laws, such as affirmatively requiring cooperation with federal immigration law enforcement activities. Such a broad, over-reaching interpretation would be subject to immediate legal challenge.

Section 8 of the executive order states: “It is the policy of the executive branch to empower State and local law enforcement agencies across the country to perform the functions of an immigration officer in the interior of the United States to the maximum extent permitted by law.” This delegation of federal immigration enforcement activities has been rejected by numerous courts, which consistently have ruled that state and local law enforcement agencies do not have the responsibility, expertise, or resources to enforce federal immigration law. However, the executive order gives authority to the Secretary of Homeland Security to declare a state or local government a “sanctuary jurisdiction” that the Secretary determines is not complying with a federal law governing communication between federal immigration officials and state and local governments (8 USC Section 1373). The Attorney General would then be authorized to act to make such a “sanctuary jurisdiction” ineligible “to receive federal grants”; it is unclear how the Attorney General could achieve this, or under what legal authority.

Section 5 of the executive order establishes priorities for federal immigration law enforcement and restores the Secure Communities program that was replaced by the Priority Enforcement Program in 2014.  The priorities stated in the executive order essentially continue the Obama Administration’s prioritization of enforcement again undocumented immigrants convicted of crimes and engaging in fraud and misrepresentation about their immigration status.  However, the addition of the subsection now prioritizing individuals who “have abused any program related to receipt of public benefits” is alarming.

The most chilling section of the executive order is section 6: “As soon as practicable, and by no later than one year after the date of this order, the Secretary shall issue guidance and promulgate regulations, where required by law, to ensure the assessment and collection of all fines and penalties that the Secretary is authorized under the law to assess and collect from aliens unlawfully present in the United States and from those who facilitate their presence in the United States.” The last phrase including “those who facilitate their presence in the United States” is vague and overbroad but could empower the Department of Justice to seek prosecution of family members, neighbors, friends, schools, employers, health and social service agencies, and almost any other individual or  institution that has contact with undocumented immigrants. While such prosecutions would be subject to legal challenges given the historical interpretation and application of current laws against “harboring” undocumented immigrants, this is a dangerous shift in executive policy.

Section 14 also authorizes the exclusion of any individual who is not a U.S. citizen or lawful permanent resident from federal privacy law protections. This would have unprecedented impact on a law such as the Health Insurance Portability and Accountability Act (HIPAA), which always have applied to all residents of the U.S., regardless of immigration status. This overbroad exclusion would revoke privacy protections for millions of Americans who have other legal immigration statuses, including those who have employment-based visas, student visas, refugees, and asylees.

While candidate and President-elect Trump never was specific about what federal “deportation force” he envisioned, the executive order now specifies the hiring of 10,000 additional immigration officers. This hiring is subject to availability of funding, which means the Department of Homeland Security adjusting its current budget to begin these hires as well as seeking additional appropriations in the yet to be finalized budget for this Fiscal Year 2017.

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Executive Order: Border Security and Immigration Enforcement Improvements

On January 25, 2017, President Donald Trump issued two executive orders about federal immigration law and policy.  This executive order focuses on immigration enforcement policies at the U.S.-Mexico border.  Consistent with his campaign pledge, this executive order states that it is “the policy of the executive branch to…secure the southern border of the United States through the immediate construction of a physical wall on the southern border, monitored and supported by adequate personnel so as to prevent illegal immigration, drug and human trafficking, and acts of terrorism”.  Interestingly, the President felt the need to define “wall” as “a contiguous, physical wall or other similarly secure, contiguous, and impassable physical barrier”. The Secretary of Homeland Security is directed to “take appropriate steps to immediately plan, design, and construct a physical wall along the southern border” and to “[i]dentify and, to the extent permitted by law, allocate all sources of Federal funds for the planning, designing, and constructing of a physical wall along the southern border”.  Given that there are no funds available in the current budget for the Department of Homeland Security for such a wall, it is unclear what actual actions can be taken towards building the wall without Congressional authorization and appropriations.

And despite candidate Trump’s campaign pledge that the government of Mexico would pay for the wall, U.S. taxpayer dollars will be used pay for the wall under this executive order. The executive order does require a report to the President about the amount of direct and indirect U.S. government funds provided to the government of Mexico during the past 5 years but there is no directive about changing that level of funding or linking it on the costs of the wall.

The executive order also directs the Secretary “to immediately construct, operate, control, or establish contracts to construct, operate, or control facilities to detain aliens at or near the land border with Mexico” and to assign immigration judges and asylum officers to those detention facilities. Significantly, the order ends the policy of releasing immigrants arrested at or near the border from detention, pending future hearings about their immigration status. This will greatly increase the number of immigrants detained, at significant costs. Additional detention facilities also would need Congressional authorization and appropriations.

The executive order also directs the hiring of 5,000 additional Border Patrol agents,            “[s]ubject to available appropriations”.  The Department of Homeland Security would have to re-allocate its current budget or seek additional appropriations to make these additional hires.

Similar to the accompanying executive order on interior immigration enforcement activities, this executive order also directs increased cooperation with state and local governments.

Finally, section 11(d) the executive order revokes the use of “parole” authority to provide temporary legal immigration status to groups of immigrants and limits that authority to individual, case-by-case decisions. Immigrants from Cuba, Haiti, El Salvador, Guatemala, and, Honduras, and Filipino World War II veterans are currently protected under this parole authority. It is not clear how what will happen to the tens of thousands of  immigrants who currently have this parole status.


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Center on Budget and Policy Priorities: Caps on Federal Medicaid Funding Would Give States Flexibility to Cut, Stymie Innovation

This issue brief from the Center on Budget and Policy Priorities describe the impact of changing federal funding provided to states for Medicaid into either block grants or per capita caps, with the explicit intent of reducing federal government spending on Medicaid. While proponents argue that such changes would provide increased flexibility to states to innovate and reduce costs, the drastic reductions in federal funding would force states to restrict access and cut benefits to Medicaid beneficiaries.

The fundamental change in funding to the states would be moving from providing a fixed percentage of Medicaid costs (which can increase with increase need and demand, especially in times of economic downturn when more Americans become unemployed or otherwise lose employer-based health insurance coverage, or have lower incomes) to a fixed amount of Medicaid funding, regardless of need or demand.  This results in a cost shift (savings to the federal government) to the states, to providers (through lower payments), and to Medicaid beneficiaries themselves (through higher cost-sharing obligations or charging premiums).

Link to Original Source


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