Today, the House passed their version of the budget framework for 2018 which they claim will pave the way for what Republicans call tax reform but is just another enormous tax cut for the top 1%. The resolution passed on a party line vote, passing by just one vote, with 18 Republicans joining all of the Democrats to oppose it. But, incredibly, the budget framework assumes that the House version of the Obamacare repeal which was never able to make it through the Senate will still become law. That would, of course, gut Medicaid and ensure that over 20 million Americans would lose health insurance.
Believe it or not, the Senate's version of the budget framework might be even worse than the House. Democrats believe that the proposal being bandied about by Senate Republicans would not only cut Medicaid by over $1 trillion but shockingly would also cut Medicare by $470 million. Both budget frameworks will once again allow the Republicans to try to use the reconciliation process which only requires 50 votes in the Senate to pass their massive tax breaks. Assuming both versions pass their respective houses, then the two versions would have to be meshed into one bill in a conference and then be passed again by both the House and the Senate before the budget extension runs out on December 8th. That's a pretty tall order considering the Republicans are trying to gut Medicaid and cut Medicare in order to allow a massive tax cut that would also increase the deficit and still require only Republican votes.
Meanwhile, while most of us have been focused like a laser beam on ensuring that ACA repeal fails, the Trump administration has been doing everything in its power to sabotage the ACA for 2018. Trump has continually threatened to stop paying CSRs, the subsidies that insurance companies rely on to help provide overage for low-income customers. He has already dropped the enforcement of the individual mandate. Charles Gaba, the ACA guru, estimates that those two measures alone have potentially raised 2018 premiums by 20%. HHS has quietly reduced the re-enrollment period, now ending it on December 15th, and has eliminated the budget for outreach and navigators to help people with enrollment. In addition, HHS will be shutting down the healthcare.gov website for 12 hours once a week for "maintenance" during the re-enrollment period.
HHS has also signaled that states could impose even more limitations on Medicaid enrollment by instituting work requirements, putting a cap on the time in the program or the amount of money spent, and even requiring more frequent re-enrollment periods.
All of these actions have knock-on effects. Higher premiums will force some unsubsidized buyers to either not get any insurance or drop down to a plan that comes with lower premiums, less coverage, and higher copays and deductibles. With no individual mandate penalty, others will also drop out of the ACA and therefore further reduce the number of people enrolled, particularly those healthy and younger, and setting the stage for more rate increases in 2019.
The last-minute push to repeal the ACA via Cassidy-Graham conveniently put a halt to the seemingly bipartisan effort to renew the CHIP program that provides health insurance for over 9 million children in this country, which expired at the end of September. Now House Republicans are using the CHIP program as a bargaining chip in the budget negotiations. There current proposal is to renew CHIP funding by using monies saved from moving the ACA grace payment period from 90 to 30 days, essentially forcing people off of ACA in order to fund health care for CHIP.
The Cassidy-Graham effort also submarined another bipartisan effort to force the President to continue to pay those CSRs that the insurance companies rely on. Now that effort, too, will become a bargaining chip in the 2018 budget negotiations.
None of these sabotages are devastating for the ACA, unlike the efforts to repeal. But they all have an effect on the edges and simply add to the continual angst that many of the people who rely on these programs have felt for the last year. As Kevin Drum notes, "it’s a little shocking that this hasn’t gotten more press attention. A president of the United States, acting out of pique, has undertaken a deliberate and calculated plan to undermine a program that provides health care to 20 million Americans at a very reasonable price. There is no feasible replacement in the works, and Republican efforts over the past year have demonstrated that even if there were, it would still take a toll of 20 million or more people." Unfortunately, after what we've seen for the last seven years, none of this should be shocking at all.
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