Legislative Update

from National Family Voices:

Health Care Legislation
When we left off with the last Update, the Senate had just rejected various versions of legislation to repeal and replace much of the Affordable Care Act (ACA), with a dramatic "thumbs down" from Senator John McCain (R-AZ). It was, and still is, unclear whether this vote will end the "repeal-and-replace" saga, but a significant development occurred just before Congress returned from recess. The Senate Parliamentarian ruled that the "reconciliation" instructions included in the FY 2017 budget resolution would not be effective after the end of the fiscal year. As a practical matter, this means that any bill to repeal the ACA or to block grant the Medicaid program would have to be considered in the Senate no later than September 30, the last day of the fiscal year. This is because any bill that does not have reconciliation status requires 60 votes to advance in the Senate. There are only 52 Republican Senators right now, and they would not be able to get eight Democrats to support such legislation. (A 50-50 tie can be broken by the vice-president.)
 
Graham-Cassidy-Heller-Johnson. Senators Bill Cassidy (R-LA) and Lindsay Graham (R-SC) haveworked over the recess to develop and gain support for a bill that would replace the ACA and Medicaid by providing block grants to states in amounts roughly equivalent to the funds the states would get from ACA subsidies and a capped Medicaid program. They are expected to release the bill text Wednesday (September 13), along with Senators Ron Johnson (R-WI) and Dean Heller (R-NV). See the 23-page summary draft and explanation of state fundingUnder this bill, the Medicaid program would no longer be an individual entitlement and states would have very few restrictions or requirements from the federal government. See There's one Obamacare repeal bill left standing. Here's what's in it. (Washington Post, 9/6/17). This bill would not be able to garner the support of 60 Senators, so to have any chance of passing it would have to go the full Senate for a vote on or before September 30, which does not seem likely at this point. See Senate GOP accepting defeat on Obamacare repeal (Politico, 9/7/17). At the moment, it looks like even the president might be giving up on ACA repeal. See Trump's 'Republicans, Sorry' Tweet Casts Doubt on GOP's Obamacare Repeal Plan (Bloomberg Politics, 9/8/17). Nevertheless, this has been a year of surprises, so it is risky to make predictions.
 
HELP Committee efforts. The time limit on a reconciliation bill enhances the appeal of bipartisan legislation to "stabilize the insurance market" so that premiums do not rise too much and insurance plans are available in all markets. The Senate Health, Education, Labor and Pensions (HELP) Committee has been holding hearings to get insights from governors, state insurance commissioners, health care stakeholders and other experts about how best to do so. Although the path ahead looks somewhat bumpy, Committee Chairman Lamar Alexander (R-TN) and Ranking Member Patty Murray (D-WA), who have a history of working together, will attempt to craft a bill that has sufficient bipartisan support to pass.
 
There is broad support in the health care and business communities for this effort. A bipartisan group of eight governors, a group of health policy experts,  businesses and health care providers, and patient organizations, have all urged the swift passage of market-stabilization legislation, particularly to ensure continuation of "cost-sharing reduction" (CSR) payments to insurers, which the administration has not promised to continue. These payments reimburse insurers for offering health plans with reduced cost-sharing, which they are required by law to provide to lower-income families. Since insurers must make final decisions about participating in the FY 2018 marketplaces by September 27, it will be necessary to pass legislation quickly to forestall insurers leaving the individual market or significantly raising premiums. See Down to the Wire: Indecision on ACA Cost-Sharing Reduction Payments Creates Confusion for States(Center on Health Insurance Reforms, Georgetown University Health Policy Institute, 9/8/17).
CHIPFundingCHIP FUNDING
 
BREAKING CHIP NEWS 
On Tuesday night (9/12), Senate Finance Committee Chairman Orrin Hatch (R-UT) and Ranking Member Senator Ron Wyden (R-OR) announced that they had reached an agreement to extend CHIP funding for another five years. The proposal would, over time, transition CHIP to its "traditional federal-state partnership" (which probably means that the 23 percentage point enhanced match would be phased out). The agreement would also provide additional protections for low-income children and flexibility for states. Details will be provided in the coming days.
 
The Children's Health Insurance Program (CHIP) is authorized through FY 2019 but funded only through FY 2017, which ends on September 30, 2017. Child health advocates, including Family Voices, have been urging Congress to extend the authorization and funding for CHIP for another five years (through FY 2022). The Medicaid and CHIP Payment and Access Commission (MACPAC), a congressional advisory commission has recommended the same. Ideally, a funding extension would have been enacted earlier this year, so that state legislatures and governors could prepare state budgets accordingly, and services could continue without interruption. States can spend any unspent funds past the end of the fiscal year, but at this point, some states are so close to running out of their CHIP funds that they will be required to send out termination notices to enrollees soon, and their ability to negotiate contracts with providers and vendors will be hampered. MACPAC has projected when each state will run out of funds. The program enjoys bipartisan support, but it is unclear when Congress will take up the CHIP legislation, and whether it will get caught up in other issues. The House Energy and Commerce Committee and the Senate Finance Committee have each held a hearing on CHIP, paving the way for the committees to take up CHIP legislation. See Congress' Tight Timetable Complicates Renewal Of Children's Health Plan(Kaiser Health News, 9/7/17).
 
APPROPRIATIONS
Congress will not be ready to pass its 12 appropriations bills for FY 2018 by the beginning of the fiscal year on October 1. In a surprise move, President Trump decided to go along with a Democratic proposal to pass a short-term "continuing resolution" (CR) to keep government agencies funded through December 8, along with an increase in the nation's debt limit until that time and $15.25 billion for hurricane relief efforts. The Republican congressional leaders had wanted a longer-term increase in the debt limit to last beyond the mid-term elections, but went along with the plan. The bill was signed into law on September 8. Democrats believe that the December 8 deadline will give them greater bargaining power to get other legislation passed before the end of the year.
The House appropriators are consolidating many of their FY 2018 spending bills, including the Labor-HHS bill, into an "omnibus" bill to be considered by the full House. On the Senate side, the Appropriations Committee approved its FY2018 Labor, Health and Human Services, and Education and Related Agencies (Labor-HHS) Appropriations Bill (press release summary) on September 7 by a bipartisan vote of29-2. The bill provides $641.7 million for the Maternal and Child Health Block Grant, the same level as in FY 2017 and as in the FY 2018 House bill. It provides $139 million for the National Center for Birth Defects and Developmental Disabilities (NCBDDD), a slight increase over last year's level. The bill also includes an increase in funding for the Children's Hospitals Graduate Medical Education program; a $2.0 billion increase for the NIH; and $816 million to address the opioid epidemic, a four-fold increase over the past two years. 
MEDICAIDCHIPMEDICAID/CHIP NEWS, INFORMATION, AND RESOURCES

Treatment of ABLE Act Accounts for Purposes of Determining Medicaid Eligibility
On September 7, the Centers for Medicare & Medicaid Services (CMS) issued a State Medicaid Directors (SMD) letter providing guidance to states about how to treat "ABLE" accounts for purpose of determining Medicaid eligibility. The Stephen Beck, Jr., Achieving a Better Life Experience Act of 2014 (the ABLE Act), enacted in 2015, created a program under which people with disabilities can save money for their disability-related expenses in tax-advantaged accounts with limited impact on their eligibility for certain means-tested benefits. The letter provides guidance to states on the treatment of funds in, contributions to, and distributions from an ABLE account for purposes of Medicaid eligibility.
 



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