By now, you’ve already seen the key takeaways from the Congressional Budget Office (CBO) score of the Senate repeal bill. But what you might not know is that the CBO score hides the most devastating of the Senate bill’s effects. Indeed, the CBO score only shows the tip of the blade that will continue to slash into Medicaid for decades to come.

According to the CBO’s analysis released yesterday, over the period of 2017-2026, the Senate’s repeal bill would:

  • Cause 22 million people to lose their health care coverage by 2026
  • Cut $772 billion from Medicaid – slashing its funding by 26 percent, and blowing a hole in state budgets which would likely lead states to cut essential programs and services for seniors, people with disabilities and children.
  • Slash the subsidies available to low- and moderate-income families by $408 billion, and leave families exposed to far higher out-of-pocket costs.
  • Eliminate the Medicaid expansion that covered millions and replace it with private coverage that the CBO says would become so expensive they would not be able to afford it. For example, a person earning $11,400 would face a deductible of more than half their annual income.
  • Lead close to half the population to lose access to critical services, such as maternity care and treatment for substance use disorders
  • All this, just to finance tax cuts for the wealthy.

But the CBO score hides the worst of the Medicaid cuts, because its projections stop in 2026 - just as the Medicaid cuts begin to sink even deeper.

Starting in 2020, the Senate bill would cap the federal contribution to states’ Medicaid programs and would force it to grow at a rate that is slower than per capita Medicaid costs (the Consumer Price Index – Medical (CPI-M) inflator for most enrollees and CPI-M plus 1 percentage point for disabled adults or age 65 or older.) Since CBO projects per capita costs of non-disabled children and adults to rise at 4.9% - but CPI-M will only be 3.7% – this change alone would result in significant reductions in states’ Medicaid funds.

But starting in 2025 – at the very end of the CBO score’s time period – the Senate bill would make far deeper cuts in Medicaid by dramatically slowing the growth of the per capita caps for all enrollees to Consumer Price Index for all urban consumers (CPI-U). The CBO projects CPI-U to grow only at 2.4% annually over this time period, while costs of non-disabled children and adults will rise at more than twice that rate.

This shift would push dramatically more costs onto states, but conveniently (for the Senate GOP leadership) it is barely captured at the tail end of the CBO’s 10-year score window. And it exemplifies how converting Medicaid into a capped funding program merely creates a dial that Congress could ratchet up for additional savings every time it needs to pay for another priority. (We already saw this in the Trump budget where they sought to add hundreds of billions of dollars in cuts on top of those that were in the House's version of ACA repeal.)

This massive cost-shift to states would only grow year after year. It would force states to eliminate life-saving services for children with special health care needs. It would deprive people living with disabilities of the services they need to live independently and it would shift new costs onto family budgets as they struggle to find ways to balance the health and long-term care needs of aging parents against other demands.

After reviewing the Senate repeal bill, the National Association of Medicaid Directors concluded, "No amount of administrative or regulatory flexibility can compensate for the federal spending reductions that would occur as a result of this bill." So as scary as the CBO score is, remember this: the worst would be yet to come.

Numerous news outlets have confirmed that the Senate is planning to hold its floor vote on ACA repeal and Medicaid restructuring next week, before adjourning for the July 4 recess week, without the benefit of any public process. Although many Republican Senators continue to decry the process, their objections are obviously just for show since it would only take three of them to stop the bill in its tracks until a more deliberative process was put in place. Yet they have continued to play the part of helpless bystanders rather than exercise the power that they actually have. As a result, a bill that has the potential to affect one-sixth of the U.S. economy, and the lives of tens of millions of people, will hit the Senate floor next week with only a minimal opportunity to assess the potential damage it would do. More details could emerge as soon as Thursday, with a Congressional Budget Office score to follow shortly thereafter, but under Majority Leader McConnell’s strategy, there will be very little time between the score release and the vote, with essentially no procedural opportunity to make improvements.

In addition to answering key policy questions, the release of Senate bill language – when it finally happens – will show how Sen. McConnell has decided to approach the political divides in the chamber: specifically, whether he will follow the House path and appease his most conservative members while daring the “moderates” to vote “no;” or whether he will, instead, take to heart Trump’s recent criticism of the “mean” House bill and actually try to produce something slightly less bad while daring the right in both the Senate, and ultimately the House, to vote “no.”

Here’s a guide to what to look for whenever the Senate language finally emerges:

In General:

Despite all the talk about starting over, expect the Senate bill to largely track the House-passed bill with a bit of window dressing thrown in that Senators will point to in an attempt to save face after having verbally panned the House plan in the hours and days after its passage.

Medicaid

More than anything else, the House version of the AHCA is at its core about drastically cutting Medicaid to pay for huge tax cuts for the wealthy and for big drug and insurance corporations. There is every indication that the Senate version will follow suit. The debate in the Senate has largely taken for granted the conversion of the Medicaid program from one that guarantees matching funds to states to one that caps federal payments and shifts costs onto the states, providers and beneficiaries. Although a bipartisan group of governors has recently raised concern about this, there has been virtually no dissension within the Senate GOP. Instead, the Senate debate has revolved around the rate of growth of those federal payments and the fate of the Medicaid expansion the ACA authorized.
A number of GOP senators have indicated that they want a growth rate no worse than the House bill’s while also killing off the Medicaid expansion more slowly – e.g., a seven-year phaseout of the enhanced federal matching funds that make the expansion possible, rather than an abrupt cutoff in 2020. Some other senators have been arguing for a more miserly federal growth rate than that in the House bill.
Look for the Senate proposal to offer a slower phaseout of the expansion than the House version’s, coupled with a stingier growth in the cap after a few years of tracking the House formula. This will be portrayed as a “compromise,” but it would in actuality be a surrender on the part of those who have been arguing that the Senate should do better than the House with respect to Medicaid. Ultimately, the coverage expansion will still be totally eliminated, while funding for older adults, people with disabilities and children is squeezed even harder as it phases out. The wild card here is that the biggest losers would be the states that did not expand Medicaid in the first place. They would get nothing at all from a slower phaseout while receiving fewer federal matching funds for their existing Medicaid beneficiary population. It is not beyond the realm of possibility that this deal could cause some Senators who are normally reliable votes for McConnell to reconsider their support.
The cap growth rate and expansion phaseout are the “marquee” Medicaid issues, but a host of details will also be important, such as what the base year will be for setting the cap, what – if any – adjustments are made over time and how caps are calculated for different populations.

Lipstick on the Pig:

While the basic Medicaid deal in the Senate is shaping up to be at least as bad as the House bill’s, rumor has it that the Senate may exclude some children with special health care needs from the funding cap. In addition, there has been discussion about including a separate fund to address opioid addiction. The notion is that these modifications would allow the GOP senators to (try to) claim that they are being less “mean.”

Marketplaces

With regard to the private non-group market, expect the Senate to rely on a tax-credit structure that adjusts for income and age but is still far less generous than that currently in effect under the ACA. We also expect that states would still be allowed to waive rules related to the benefit package but that plans would not be allowed to charge higher premiums to people with pre-existing conditions. People with expensive medical needs would still be harmed, though, because without a comprehensive benefit package, a lot of the cost of care could be shifted back to individuals.

Access to Reproductive Health Services

Look for the defunding of Planned Parenthood to remain in the bill. Although senators Collins and Murkowski are likely to offer an amendment to strike that provision, such an amendment will probably fall short on a 50-50 tie. The question then will be whether either or both these senators will vote “no” on final passage, thereafter. In addition to defunding Planned Parenthood, the House bill tries to prohibit tax credits from being used for any insurance plan that covers abortion services. This provision will probably be struck as a violation of Senate budget reconciliation rules, but the Senate is looking for an alternative route to achieve the same objective.

Taxes

To the extent that there is a need for additional revenue to meet the House deficit reduction target, the Senate will likely delay the effective date of some of the tax cuts that are in the bill. In the alternative, they could temporarily suspend some of the tax cuts with an expectation that they could do a full repeal later.

Where Are the Votes?

Despite the haste, or perhaps because of it, it remains unclear whether the votes to achieve passage are there in the Senate. At the risk of oversimplifying: to get the requisite 50 votes for the Senate bill to pass – with a tie-breaking “yes” vote assist from Vice-President Pence – McConnell will have to keep at least four of the six Senators who comprise the most conservative and most moderate flanks of his caucus – Cruz, Lee, Paul on the right and Collins, Murkowski and Capito in the middle. He will also have to keep Sen. Heller of Nevada on board – the most endangered member of the GOP caucus up for reelection in 2018, being from a state that has benefited greatly from the ACA. Sen. McConnell has to do those things while also preventing any other defections from senators whose states stand to lose big time in numerous ways under this bill (which is really kind of all of them).

With thanks to Quynh Chi Nguyen, policy analyst, for her assistance.

This blog is part of a series that will highlight how structural racism in the health care system negatively affects the health of individuals of color. Community Catalyst is committed to exposing and dismantling policies, practices and attitudes that routinely produce cumulative and chronic adverse outcomes for people of color in the health system.

While LGBT Pride celebrations are in full force, LGBT people continue to remain deeply concerned about federal attempts to curtail health access, equal rights and non-discrimination protections that are moving forward on many different fronts. Repealing the Affordable Care Act would remove rules that protect LGBT people from discrimination in health care settings. LGBT immigrants in particular fear the Trump Administration’s plans to deport millions and restrict health services, and Congressional leaders are introducing legislation to restrict health care access to immigrants.

As social justice advocates challenge the administration on immigration, health and equality, it is important to understand the communities tangled within systems of oppression – racism, homophobia, transphobia, xenophobia – to ensure advocacy strategies are inclusive of and responsive to the needs of the most vulnerable. When discussing how health policies impact LGBT people, we assume all LGBT people are citizens. When we implement strategies to conduct outreach to immigrant communities, we forget that there are immigrants who identify as LGBT. LGBT immigrants have unique experiences due to their immigration status, sexual orientation and gender identity. Health advocacy strategies and policies must reflect these experiences to promote health equity and reduce health disparities for LGBT immigrants.

The US is home to approximately 904,000 LGBT immigrants. Nearly one-third (267,000) are undocumented. While the uninsured rate for LGBT people has dropped under the ACA, LGBT immigrants are largely restricted from accessing health coverage and continue to have one of the highest uninsured rates.

LGBT immigrants, like LGBT people overall, are at risk for negative health outcomes such as alcoholism, depression and cancer due to stigma and stress associated with discrimination. HIV is also a growing epidemic within immigrant communities. Mental health issues are also common due to constant fear of being deported and detained. Trans immigrants, for example, are mistreated and discriminated in detention centers with no access to appropriate health services. Plus, President Trump’s Muslim ban has threatened the lives of LGBT and HIV-positive refugees seeking asylum who are stuck in regions that criminalize homosexuality. President Trump recently announced he would keep the Deferred Action for Childhood Arrivals (DACA) program, but 36,000 LGBT DACA recipients still fear he will abolish it over time and trigger their deportation. 

The intersecting systems of oppression behind the exclusion of LGBT immigrants from health coverage deepens negative health outcomes. LGBT immigrants have little to no options for accessing prevention services. While states such as California and New York have enacted coverage expansions for young low-income immigrants, undocumented and “DACAmented” LGBT immigrants are excluded from purchasing ACA plans and enrolling into Medicaid or CHIP. LGBT mixed status families in states that have not adopted the Legal Immigrant Children’s Health Improvement Act (ICHIA) must wait five-years before being eligible to enroll. Homophobia and transphobia within the health care system also keeps LGBT immigrants from accessing health services and widens health disparities. Trans immigrants have reportedly been refused care by their providers due to their gender identity.

Advocates could take following steps to undo the systems of oppression facing LGBT immigrants.

  • Promote LGBT cultural competency training for health care-related students and professionals to eliminate discrimination in health care settings.
  • Collaborate with and support LGBT and immigrant rights organizations.
  • Support campaigns that aim to protect the privacy of immigrants access health services.
  • Join efforts to expand health coverage opportunities for undocumented and DACAmented LGBT immigrants.
  • Build meaningful relationships with state and local groups to foster community dialogue and raise awareness about LGBT-specific issues.
    • Equality New Mexico, for example, tailors its outreach, education and enrollment resources for LGBTQ Latinx and immigrant communities. Make the Road NY serves LGBT Latinx people and has Spanish-speakers conducting outreach in hard-to reach communities.

As LGBT immigrant communities continue to live in fear amidst leaked executive orders and anti-immigrant rhetoric, it will be critically important for advocates to use an intersectional lens to engage community members experiencing multiple levels of discrimination who are at most risk of losing any access to health coverage and care.

Even close readers of the news can be forgiven for not understanding how perilously close the Senate is to not only ripping coverage away from millions of people, but also cutting Medicaid funding for children, seniors and people with disabilities and putting a vice around the program. After all, there continue to be multiple conflicting reports relating to the content, timing and degree of agreement among Republican senators. So, without further ado, your handy guide to what we know and don't know about where things stand in the Senate.

More like the House bill than not

Despite all the denials and claims that they are starting over, the House bill will provide the basic architecture of what the Senate does. It is not the case that the Senate will bring the House bill to the floor and then replace it with a substitute that looks much different. The key elements of the House bill – eliminating the Medicaid expansion, capping federal Medicaid funds to states, slashing tax credits and cost-sharing assistance in a way that particularly harms lower-income and older people, undermining insurance market protections for people with preexisting conditions, and big tax cuts for the rich and for insurance companies and the drug industry – will all likely be retained in the Senate proposal.

Less opposition than you might think

There is more support in the GOP Senate caucus for this "basket of deplorables" than people may realize based on senators’ public statements. In particular, it would be a mistake to conclude that members who have expressed skepticism that the Senate will pass a bill will themselves ultimately be a “no” vote. Everyone is still leaving themselves with a lot of wiggle room, and many of the most vocal Senate critics of the House proposal have begun making positive noises about the Senate bill, even though it will be very similar (Senator Cassidy, a case in point).

Sooner rather than later

The issue is coming to a head sooner rather than later – McConnell wants to get off of health care and move on to other matters like reforming the tax code. We are expecting a Senate vote before the July recess begins on June 30, though it is not impossible that it could slip until immediately after the recess. That doesn't mean the Senate Majority Leader will just throw a bill out there and figure “if it fails, it fails.” The public comments following the Republican caucus last week suggest that he is making headway toward getting the 50 votes he needs.

Don't expect to see the bill in advance

The exact contours of the Senate proposal will be kept from the public (and the members) until the very last minute. While the situation is serious, some important decisions and significant fault lines remain, including:

  • Medicaid: With respect to Medicaid, the timing of the phaseout of the expansion remains uncertain. A number of senators are on record in support of a seven-year phaseout of enhanced federal match. While the disastrous end results would be the same, there appears to be a sense among the "moderates" that a slower phaseout provides better optics and ideally – from their point of view – delays the worst consequences of the bill until after their next reelection bid, whether that falls in 2018, 2020 or 2022.
  • Per Capita Cap Growth Rate and Base Year: There has been an ongoing debate between senators who want to keep or improve on the growth rate in the House bill and those who want to cut Medicaid spending even more than the $839 billion in AHCA. There have been rumors of a trade between a lower growth rate and a longer phaseout of the expansion, but at this point those remain rumors. Meanwhile, both the growth rate and the base year of the cap have emerged as potential flash points. Some senators from low-spending states have voiced concerns about being unfairly locked into lower federal reimbursement rates in perpetuity.
  • Tax Credits: The Senate will try to add some money back to the House proposal to soften the blow on lower-income and older adults, but they are unlikely to have enough money to prevent a massive drop off in insurance coverage. The question is whether that will deter any senators from voting for the bill and whether we will even know the CBO estimate of the effect on coverage before the Senate votes.
  • Tax Cuts: Expect the Senate proposal to mirror the House but with delayed effective dates to help pay for the slower phaseout of the Medicaid expansion and for adding money to the tax credits.
  • Consumer Protections: The provision allowing states to let insurers charge people more if they are sick or "high risk" will likely fall out, but state waivers of Essential Health Benefits at this point appear likely to stay in. With dramatically lower premium support, states will be under pressure to cut down the benefit package whether they want to or not. The result will be a big spike in out-of-pocket costs, particularly for people with serious and expensive health conditions.

While the Senate is trying to speed toward the floor, some process challenges remain that have not been fully worked through. Three are worth keeping an eye on:

1. Cost Sharing and the Indian Health Service

Democrats are arguing that the provision of the law that eliminates cost-sharing assistance touches on the jurisdiction of the Indian Affairs Committee. Since that committee did not receive reconciliation instructions, sending the bill over to the Senate as-is could remove the protection of the reconciliation process and subject the bill to a 60-vote requirement, under which it would certainly fail. To avoid this, the House would have to amend the bill before it is formally transmitted to the Senate.

2. Allocation of Savings

In order to comply with the reconciliation instructions, which are what enable the bill to move forward with a simple majority, both the HELP and Finance committees must identify at least $1 billion in savings. Senate Budget Committee Chair Enzi has asserted both that the bill meets that test and that he is the arbiter of whether it does or doesn't. Ranking minority member Sanders is arguing that the bill fails the test and that the Parliamentarian must make a ruling.

3. Abortion

The House bill prohibits tax credits from being used for plans that cover abortion. This could run afoul of the Byrd rule, which requires provisions in a reconciliation bill to have a more-than-incidental effect on the budget. If the language is stricken, anti-choice legislators in either the Senate or House could withdraw their support from the tax-credit provisions entirely, which could sink the bill.

Even as more moderate members have indicated that they are encouraged, the most reactionary members are starting to voice concern and displeasure. Since McConnell can’t afford to lose three votes in the Senate, opposition from Senators Paul, Lee and Cruz, among others, could sink the bill.

With all of the uncertainty swirling around, McConnell still has two main paths to getting a bill through the Senate (and ultimately to final passage). First, he could get all the moderates on board while losing only two from the far right. Then, back on the House side, if some Freedom Caucus members flip to “no,” their votes could be offset by House members who voted “no” on AHCA in May but now could hide behind the largely cosmetic changes in the Senate: this could allow the Republicans to eke out a narrow victory. In the alternative, McConnell could follow the path of the House, appease the far right and dare the shaky moderates to vote “no.”

One thing we do know for sure: Unless the GOP skeptics of the House bill face an outpouring of resistance in the next few weeks, we are likely to see not only a rollback of the progress made since 2009 but also a fundamental undermining of the health care safety net that has been in place since 1965. That ought to make America great again.

With thanks to Quynh Chi Nguyen, policy analyst, for her assistance.

Another year means another LGBTQ Pride season, and another reason to celebrate significant gains in LGBTQ health thanks to the Affordable Care Act (ACA). What are we celebrating in 2017?

For one, more LGBTQ people have health insurance than ever before. Thanks to the ACA, the uninsured rate for low- and middle-income LGBTQ people is at a record low, dropping from a high of 34 percent in 2013 to 22 percent in 2017. Overall, the uninsured rate for this group of LGBTQ people fell by 35 percent since the ACA’s major reforms went into effect. Although we still have a lot of work to do to address LGBTQ health disparities—like higher rates of HIV and tobacco use—access to quality, affordable health insurance has helped our communities begin to close these gaps.

In addition, 2017 was the best year ever for transgender people to enroll in health insurance.  Thanks to a new ACA rule that went into effect in 2017, most private insurers can no longer include plan language that discriminates against transgender people (known as transgender exclusions) or otherwise discriminate against LGBTQ people in health coverage or care. This means that new insurance plans, while still far from perfect, are better than ever: our analysis in December 2016 found that the vast majority of silver marketplace plans in 16 states had removed transgender exclusions. Even better, nearly 20 percent of plans had language indicating that all or some medically necessary transition-related care would be covered. Although there is still more work ahead of us to improve health care for transgender people, this—plus the fact that 14 states and DC now affirmatively cover transition-related care in their Medicaid programs—shows significant progress.

Despite these gains, LGBTQ health is under attack. Instead of building on the progress the ACA made, members of Congress and the Trump administration want to take health care from millions, including an estimated 1 million LGBTQ Americans, and gut essential nondiscrimination protections. The American Health Care Act—passed by the House and currently under consideration in the Senate—would strip insurance from 23 million Americans, hike premiums by 20 percent next year, and cut $834 billion from Medicaid, all while eliminating protections for people with preexisting conditions. These are just some of the changes that Congress is considering to give tax breaks to the wealthy while cutting billions of dollars from programs that low- and middle-income LGBTQ families rely on.

At the same time, the Trump administration has threatened to roll back parts of Section 1557 of the ACA, which bans sex discrimination in health care programs that receive federal funding and is critical to ensuring that LGBTQ people are treated respectfully when accessing coverage and care. Because Section 1557 is not subject to the budget reconciliation process, Republicans in Congress cannot repeal this part of the ACA, so Section 1557 is likely to remain in place at least for the near future.

However, parts of the Section 1557 regulation—a rule issued by the Obama administration that was finalized in May 2016—have been challenged in federal court. The plaintiffs in the litigation, Franciscan Alliance v. Price, challenged the Obama administration’s interpretation that the ACA’s ban on sex discrimination prohibits discrimination based on sex stereotyping, including gender identity. Judge Reed O’Connor—the same judge who blocked the Obama administration’s efforts to protect transgender students—agreed with the plaintiffs and issued a nationwide preliminary injunction on December 31, 2016.

Although a setback, this injunction is temporary and applies only to the Office for Civil Rights at the U.S. Department of Health and Human Services (HHS). Under this ruling, HHS is barred from enforcing Section 1557’s protections for transgender people. However, the Section 1557 rule itself remains firmly in place. This means that covered entities, such as hospitals and state Medicaid programs, must continue to comply with Section 1557, and LGBTQ people continue to be protected from discrimination in health insurance and health care. We can’t emphasize this enough: LGBTQ people should never face discrimination and, if you do, you have rights and should contact Out2Enroll or a legal organization for help.

Advocates should also be aware that HHS has asked Judge O’Connor to stay the litigation to allow the Office for Civil Rights to reconsider the Section 1557 rule. We are currently awaiting his decision on this issue, but advocates should be prepared to educate and activate your networks about the importance of Section 1557 if and when the rule is reopened.

Thank you for everything you’re doing this Pride season—from spreading the word about enrollment at Pride festivals, to calling members of Congress to ask them to protect the ACA—and for your ongoing commitment to LGBTQ health. Out2Enroll and Community Catalyst will continue to keep you posted on new developments and what you can do to promote LGBTQ health equity.

Katie Keith is a member of the Steering Committee at Out2Enroll