Goal is to defend health care gains, social programs against cuts
By JUDITH VANDEWATER
WASHINGTON, D.C. — The first 10 months of the Trump presidency brought back-to-back Republican-led attempts to repeal, replace or debilitate the Affordable Care Act. Although those efforts have largely been held at bay to date, and tax cut legislation has replaced health care as the principal focus of the Trump administration and Congress, issues on the congressional must-do list this year could have lasting negative impact on the ministry, on the health care finance system, and on low-income and otherwise vulnerable populations.
Visits to Capitol Hill were on the agenda for attendees at CHA's Legislative Advocacy Conference Oct. 26-27. Here, J.R. Sanchez, left, of Sen. Marco Rubio's staff, meets with Marco Paredes, center, the associate director for health for the Florida Conference of Catholic Bishops; and Kip Corriveau, mission director of Bon Secours St. Petersburg Health System. Sanchez is senior policy advisor and director of outreach for the Republican senator from Florida.
© CHA/Rick Reinhard
That was the crux of the call to vigilance and action delivered by government affairs experts at CHA's annual Legislative Advocacy Conference held here in late October.
"This has been a very long, tedious, trying time," Sr. Carol Keehan, DC, CHA's president and chief executive officer, told an audience of ministry members involved in advocacy and public policy for Catholic hospitals and health systems. In response to urgent appeals from CHA, many of those in attendance have repeatedly rallied colleagues and community members this year to contact their elected representatives. Sr. Carol said those constituent calls have helped defend hard-won gains for vulnerable Americans.
"We have prevented catastrophe after catastrophe," Sr. Carol said. "Quite frankly, I'm here to say to you, as grateful as I am, I will still be banging at your door. I don't know when we have had so many critical issues facing us."
Advocacy priorities
High on CHA's list of advocacy priorities is an effort to restore funding for cost sharing reduction subsdies eliminated by the Trump administration in October. Those subsidies lower the amount low-income people pay out-of-pocket expenses for insurance purchased in the ACA marketplaces. CHA has pledged cooperation in advancing the Senate's Bipartisan Health Care Stabilization Act of 2017. This bill would shore up the health care marketplaces by reinstating subsidies for two years.
CHA is supporting that effort over a competing plan put forward by Sen. Orrin Hatch, R-Utah, and Rep. Kevin Brady, R-Texas. That plan would restore cost sharing reduction payments for two years, but it would weaken the ACA and destabilize insurance markets by eliminating the individual and employer mandates for insurance.
"Some are calling it repeal light," said conference speaker Allison Orris, a regulatory policy expert and counsel in the Washington office of Manatt Health. Orris said uncertainty over the future of cost sharing reduction subsidies helped fuel price increases for marketplace plans in the open enrollment period which began Nov. 1.
Many states had planned for the end of cost reduction subsidies and had instructed insurers to build the value of the subsidies into the premiums for their products. In states where that occurred, consumers with incomes within 100 percent of poverty to 400 percent of poverty will get tax credit offsets that cover the premium increases for the 2018 plan year, Orris said. However, even in those states, consumers who earn too much to qualify for the tax credits likely will pay more than they otherwise would have for marketplace coverage.
Other advocacy priorities for CHA in 2017 include:
- Reauthorization of funding for the Children's Health Insurance Program, which expired at the end of September. At least 12 states are expected to exhaust their CHIP funds by the end of this year.
- Securing a two-year delay in scheduled reductions of Disproportionate Share Hospital adjustment payments. The payments benefit hospitals serving large numbers of uninsured and underinsured patients.
- Supporting the DREAM Act to codify protections from deportation for young adults in the Deferred Action for Childhood Arrivals program, known as DACA, and for other young immigrants.
Conference speakers said that all three of those issues could be rolled into omnibus or catchall bills that are put to a vote in December. Conference speaker Mike Smith, a principal of Cornerstone Government Affairs, said that, given divisions between traditional conservatives and populists in the Republican party, it appears likely that Republicans will need Democratic votes to pass an appropriations bill and a bill to raise the debt ceiling. "Because of that you'll see issues like DACA addressed in a year-end spending bill, or you won't see a year-end spending bill," he said.
Speaker Tamara Fucile said to get DACA reauthorization included in an omnibus spending bill, Republicans could demand a significant increase in spending on border security — possibly to include funding for a border wall in Southwestern states. Fucile directs government affairs for the Center on Budget and Policy Priorities, a nonpartisan research and policy institute that studies how state and federal budget choices impact low-income individuals and families.
Any increase in spending authorized by Congress, including the border wall and up to $300 billion in additional hurricane and wildfire disaster relief, likely would have to be offset by cuts in other programs, Fucile said. This opens a number of health care and social service programs to the threat of budget cuts, she said.
Orris said that final action on CHIP funding may be pushed into December and wrapped into other "must pass" legislation. The House passed a bill Nov. 3 that extends funding of CHIP for five years. This bill, "The Championing Healthy Kids Act of 2017" would eliminate $2 billion in scheduled reductions to DSH payments for fiscal year 2018 and $3 billion in fiscal year 2019.
Speakers said protecting the budgets of Medicaid and Medicare and other social safety net programs will require ongoing effort, especially because deep tax cuts proposed by Republicans will have to be paid for with new revenue streams or with spending cuts.
"What we are defending cannot be rebuilt in these current times," said Smith, who consults with CHA on legislative strategies. His clients include Democratic candidates and elected officials at the state, local and federal levels. "The social programs you have led with," he told the CHA audience, "they are not going to be easily replicated once they are taken away."
Fucile explained that the congressional budget resolution that set a framework for the tax cut legislation is designed to allow the bill to move quickly through Congress and pass with a simple majority of votes in the Senate.
The rules and the accelerated schedule conceivably would allow Republicans to pass a comprehensive tax bill without one Democratic vote and put it on President Trump's desk for a signing ceremony on Christmas Day. Fucile said she thinks it more likely the effort to pass the tax cut legislation will extend into early 2018. The last comprehensive tax reform was enacted in 1986, and was the product of a bipartisan and collaborative process. "We are seeing a very different process this time around," she said, cautioning that the tax cut legislation will have a deep impact across all sectors of the U.S. economy.
Fucile said the framework for the tax cut sought by Republicans allows the deficit to grow by $1.5 trillion over 10 years, but her organization expects Republicans will write a tax cut plan that cuts revenues by about $2.5 trillion. She said Congress will have to make up that $1 trillion difference with program cuts or revenue increases. "What we are concerned about is that the primary way to make up that difference is to look for cuts in programs. And, because of the jurisdiction of the committees that write tax legislation, there are a lot of health programs at risk," she said.
"We are concerned there will be a tax plan that largely benefits the wealthiest and does little if anything for low- and mid-income families. And, at the end of the day, it is the programs that benefit low- and middle-income families that will need to be cut to pay for this tax plan," she said.
Fucile said leaders in Congress have said they will implement tax cuts first followed by efforts to offset those cuts. "We may not see health care cuts immediately when they do the tax cut, but what we expect and what they have said is they are going to do tax cuts now and spending cuts and welfare reform later."