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This week the U.S. Senate had a goal of voting on the “Better Care Reconciliation Act of 2017” – the earlier version of the bill that was passed in the House of Representatives this year.  Fortunately, the Senate decided to chill and not to take the vote this week or next.  Hopefully they’ll reflect over the July 4 break and come back with a more productive approach to improving on the ACA.

The nonpartisan Congressional Budget Office released it’s analysis of the Senate Bill (https://www.cbo.gov/publication/52849), which seems to have had a profound impact on the negotiations.  The report found that the proposal would have increased the number of people who are uninsured. It is estimated that 15 million more people would be uninsured by next year. The increase in the number of uninsured people would reach 19 million in 2020 and 22 million in 2026.

In later years, lower spending on Medicaid and substantially smaller average subsidies for coverage would lead to even more increases in the number of people without health insurance. By 2026, enrollment in Medicaid would fall by about 16% and an estimated 49 million people would be uninsured, compared with 28 million who would lack insurance that year under the ACA.

Another interesting development this week was a new analysis released by AHCCCS concluding that the proposal would cost our state at least $7.1 billion through 2026. Download the full report from the AHCCCS website.            

The analysis shows that the Bill increases costs for Arizona by $2.9 billion between FY 2018 and FY 2026.  It would make changes to the enhanced federal funding provided for the 320,000 Medicaid members that are childless adults with incomes up to 100% of federal poverty, as well as 82,000 adult members with incomes between 100-133% of federal poverty.   

We’re encouraging AzPHA members to send messages to our Senators urging them to focus on supporting a Senate bill that decouples the issues related to the individual health care insurance market from these dramatic changes to federal and state Medicaid programs.

Senator Jeff Flake
Russell Office Building 413
Washington, D.C. 20510
(202) 224-4521
Twitter: @JeffFlake

Senator John McCain
Russell Office Building 218
Washington, DC 20510
(202) 224-2235
Twitter: @SenJohnMcCain

This morning the U.S. Senate released draft healthcare legislation entitled the “Better Care Reconciliation Act of 2017”.  Note that it has a different name than the House version that passed a few weeks ago (American Health Care Act).  In many respects, the two bills are very similar.

They’re calling this a “discussion draft”, implying that it’s possible that the language of the bill could morph before it hits the Senate floor next week.

The non-partisan Congressional Budget Office is still working on an evaluation of the Senate version.  That evaluation will provide a better picture of the practical impacts that the bill would have if enacted, however, here’s what we know from the initial reading of the discussion draft: 

• Like the House version, BCRA would give states either a per capita cap for federal Medicaid contributions or a block grant of funds beginning in 2020. It appears that, unlike the House version, federal funds for kids the elderly and people with disabilities could not be “block granted” (an improvement).  On the down side, the inflation rate used to calculate future per capita contributions would be even lower than the inflation rate in AHCA which will result in less Medicaid spending in 2025.

• Rolls back the Medicaid expansion (to 138% of poverty), but more slowly than the House version. Would creates some kind of state innovation fund for states that didn’t expand Medicaid.

• Eliminates the individual mandate for everybody to have health insurance.

• Eliminates the requirement that larger employers provide health insurance to their employees.

• Insurance companies would still not be allowed to increase premiums or deny coverage based on preexisting conditions.

• States would be allowed to change what qualifies as an essential health benefit for Marketplace plans.

• Completely eliminates the Prevention and Public Health Fund (PPHF) in FY18, which is used by every state to support vital public health programs that promote health, prevent disease, and allow for rapid response to emerging public health threats.

The Century Foundation has a good comparison of the House and Senate Versions as well as the current law under the Affordable Care Act on their website here:  https://tcf.org/content/commentary/heart-comparison-house-senate-health-bills/   ;

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We’re encouraging AzPHA members to send messages to our Senators urging them to focus on supporting a Senate bill that: 1)  protects futue funding for Medicaid; 2) allows folks with pre-existing conditions to be able to continue to have access to affordable health insurance; and 3) protects the Prevention and Public Health Fund.

Senator John McCain

Washington, DC Office:       202.224.2235

Phoenix Office:                    602.952.2410

Senator Jeff Flake

Washington, DC Office:       202.224.4521

Phoenix Office:                    602.840.1891

There’s been a promising increase in public health policy focus in recent weeks regarding Arizona’s ongoing opioid epidemic. 

A few weeks ago the Arizona Department of Health Services (ADHS) released the 2016 Arizona Opioid Report which found that there were 790 deaths in 2016 in Arizona from opioids, a 16% increase from 2015 and a 74% increase since 2012.  More than half of the increase in the last two years have been heroin deaths (heroin increased from 11% of opioid deaths in 2007 to 39% in 2016).

Shortly after the report was released, the Governor declared a Public Health State of Emergency charging the ADHS with developing: 1) an enhanced opioid surveillance protocol; 2) new emergency regulations for prescribing opioids among licensed healthcare institutions; 3) additional provider practice guidelines; 4) Naloxone use guidelines for law enforcement; and 5) a report of findings that include possible additional legislative action by September 5, 2017.

Last week the ADHS launched an opioid website at www.azhealth.gov/opioid which houses information about the opioid epidemic including information for those required to report data, and resources for law enforcement and EMS and  clinicians as well as standing orders for naloxone dispensing.

These latest administrative actions are just the latest in a string of interventions in Arizona regarding the opioid epidemic.  In October 2016 the Governor issued an Executive Order charging AHCCCS with limiting  Initial Opioid prescriptions to 7 days.  On January 9, 2017 he signed an Executive Order that establishes a substance abuse program for people leaving prison at risk for opiate abuse.

Last legislative session, the Legislature passed HB 2493, which will set up a drug overdose review team at the ADHS (much like the child fatality review team).  It’ll be a 21-member consisting of nine heads of various government entities (or their designees) and 12 members that will:

• Develop a data collection system regarding drug overdoses;
• Conduct an annual analysis relating to drug overdose fatalities;
• Develop standards and protocols;
• Provide training and technical assistance to local Teams;
• Develop investigation protocols for law enforcement and the medical community;
• Study state and local laws, training and services, recommend policies to decrease drug overdose fatalities; and
• Educate the public regarding drug overdose fatalities.

In addition to all of these interventions, AHCCCS has received a  State Targeted Response Grant ($24M over the course of 2 years) from the Substance Abuse and Mental Health Services Association to increase access to medication assisted treatment, care coordination for high risk individuals, recovery support services and prevention activities to reduce opioid use disorders and deaths.  The project will also develop and support state, regional, and local level collaborations, build capacity and infrastructure and service enhancements in high need areas.

The proposed activities within the Arizona Opioid State Targeted Response project will: 1) create a new streamlined data-driven decision-making process to target and tailor treatment and prevention resources where they are most needed in the state; 2) expand training for prevention and treatment providers; 3) expand law enforcement access to Naloxone kits; 4) expand access to MAT and integrated treatment; and 5) expand peer support services, recovery homes and recovery supports to pregnant and parenting women. 

We’ll continue to track the policy interventions that are underway and update our AzPHA members on the latest surveillance and intervention activities.

Last week the Nevada State Legislature handed Governor Sandoval an opportunity to provide the U.S. Senate a template for modifying the Affordable Care Act.

The Nevada Legislature approved a bill and sent it to the Governor’s desk that would allow any Nevadan to “buy in” to their state’s Medicaid program.   If the Governor signs the bill (and if the Centers for Medicare and Medicaid Services – or CMS –  approves the plan) any Nevadan would be allowed to buy managed care health insurance through their state Medicaid program.  The bill would allow the purchase regardless of income. Nevada residents that qualify for their current Medicaid program would continue to receive services as-is.                  

The actual Bill is called Assembly Bill 374.  If it’s signed, the new law would direct the Nevada Department of Health and Human Services to ask CMS for a Waiver allowing their Medicaid agency let Nevadans buy health insurance through their Medicaid managed care program.  If the law is signed by their Governor (and if the approach is approved by CMS) the Medicaid insurance would be available for purchase on the “Silver State Health Insurance Exchange”.  The plan calls for folks who qualify for tax credits under the Affordable Care Act to be able to use their credits to help pay for the coverage. 

Nevadans would need to pay an annual premium “… representing 150% of the median expenditure paid on behalf of a Medicaid recipient during the immediately preceding fiscal year“.   The coverage would be the same as the coverage for NV Medicaid recipients except it wouldn’t cover emergency medical transportation (e.g. ambulance rides).  The measure is written to ensure that no federal funds would be used.

The plan has several advantages that cover many of the consensus areas that most Americans agree with… that folks should have access to reasonably priced health insurance regardless of whether or not they have a pre-existing condition. This relatively simple plan would accomplish that without a complicated overhaul of the healthcare system since all states have existing Medicaid programs. 

I often hear people arguing that a solution to the healthcare debate is to adopt a “Medicare for All” plan…  and I’ve wondered why there’s never been much discussion of a Medicaid buy-in option.  It solves a lot of the issues that the exchanges struggle with because the risk pool is larger and the rate negotiation much bigger than in the individual market today.  That means lower costs and less volatility.

Arizona would be in a good position to lead the way with such a plan.  Our state Medicaid program (called AHCCCS) is widely recognized as an efficient and cost-effective model for providing Medicaid coverage. In addition, AHCCCS’ legislation already provides the enabling statutory language to allow state employees to buy into Medicaid- so the buy-in concept isn’t entirely foreign. 

To make it work, the actuarial rates would need to be calculated in order to set the premium levels for buying in to AHCCCS.  With ACA tax subsidies and cost sharing reductions, the out of pocket costs per person would be competitive or less expensive than plans currently offered in Arizona’s Marketplace, with less year-to-year volatility in pricing.

Sometimes solutions to complicated problems are staring you right in the face.

A couple of weeks ago he nonpartisan Congressional Budget Office (CBO) released its final analysis of the House Republican’s American Health Care Act (AHCA) which was passed by the US House of Representatives by a vote of 217-213 on May 4.  The Vote in the House came before the CBO evaluation of the Bill.

CBO’s new analysis of AHCA estimates that 14 million Americans would lose health insurance in 2018.  By 2026 they estimate that 23 million would lose health insurance under the House version of AHCA. 

The measure would convert federal Medicaid (AHCCCS) funding to a per capita allotment and limit growth beginning in 2020 (using 2016 as a base year).  States could also choose to receive Medicaid funds as a block grant instead of the per-capita allotment. These are troublesome provisions that shift financial risk to AZ from the federal government …  setting up an environment that increases the likelihood that we would have future reductions in eligibility and covered services for Arizonans that get their health insurance through Medicaid (including vulnerable populations).

The Bill would also shift more of the cost of care to consumers through higher out-of-pocket expenses. Premiums could go down for some people, but premiums for low-income Americans and seniors would increase.  Subsidies would shift from income-based to age-based, with subsidies increasing with age.

It would also eliminate the Prevention and Public Health Fund beginning in 2019, block Planned Parenthood from receiving Medicaid reimbursements for services (for one year).

The Kaiser Family Foundation has a very helpful set of resources on their website that helps explain the differences between the current health care law and what would happen if the AHCA were enacted as passed by the US House of Representatives.

The Bill as passed by the US House of Representatives would:

• Convert federal Medicaid (AHCCCS) funding to a per capita allotment and limit growth beginning in 2020 using 2016 as a base year and provide states the option to get a block grant instead of the per-capita allotment. 

• Editorial comment: this provision (in my opinion) the most problematic proposal in AHCA as it would shift financial risk to AZ from the federal government and set in motion a sequence of events that would likely result in reductions in eligibility and covered services for vulnerable Arizonans. 

• Sunset the federal funds that paid for Medicaid expansion (to 133% of federal poverty) on January 1, 2020 except for people enrolled in the expansion population on 12/31/19 and who don’t have a break in eligibility of more than 1 month.

• Replace the current income-based tax credits with flat tax credits adjusted for age. Eligibility for new tax credits phases out at income levels between $75,000 and $115,000.

• Impose late enrollment penalty for people who don’t stay continuously covered.

• Repeal the Prevention and Public Health Fund at the end of Fiscal Year 2018.

• Encourage use of Health Savings Accounts by increasing annual tax- free contribution limit and through other changes.

• Establish a fund ($115 billion over 9 years available to all states), and additional funding of $8 billion over 5 years for states that elect community rating waivers (let insurance companies charge more for people with pre-existing conditions). States could use the money to provide financial help to high-risk individuals, promote access to preventive services, provide cost sharing subsidies, and for other purposes.

Our parent organization, the American Public Health Association,issued a statement highlighting the CBO’s findings and urging the Senate to work in a bipartisan manner that builds on the strengths of the Affordable Care Act.

We’re encouraging AzPHA members to send messages to our Senators urging them to focus on supporting a Senate bill that, first and foremost, protects Medicaid and that also allows folks with pre-existing conditions to be able to continue to have access to affordable health insurance.

Senator John McCain

Washington, DC Office:        202.224.2235

Phoenix Office:                    602.952.2410

Senator Jeff Flake

Washington, DC Office:        202.224.4521

Phoenix Office:                    602.840.1891