Caitlin Owens
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54% of voters view AHCA unfavorably: poll

AP file photo

A new poll conducted for Protect Our Care, a pro-Affordable Care Act grassroots group, found 54 percent of voters have an unfavorable opinion of the House health care bill and lays out what changes they think the Senate should make.

Particularly unpopular: the bill's treatment of pre-existing conditions and its provision allowing older people to be charged higher premiums related to younger people than under current law.

Other highlights of the poll, which was taken before the Congressional Budget Office released its report on the bill on Wednesday:

  • 40 percent have a favorable opinion of the bill.
  • 80 percent say the provision allowing older people to pay higher premiums raises big concerns.
  • 78 percent say the provision allowing people with pre-existing conditions to pay higher premiums raises big concerns.
  • 62 percent say they want the Senate to work on a bill that keeps what works under the ACA and fixes what doesn't.
  • 79 percent think changes to the health care system should be bipartisan.
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Senate will start putting together draft health care bill next week

(Jacquelyn Martin / AP)

After three weeks of working group meetings, Senate Republicans will begin drafting their version of a health care bill over next week's recess.

"Over the break, initial legislation will be drafted, and then we'll have more time — we'll actually have a basis to discuss on these things," Sen. Ron Johnson told reporters, saying leadership and committee staff will write the bill.

What to watch: While we expect the Senate bill to take on some the same basic policy structure as the House bill, some pieces are subject to change — particularly after the release of the Congressional Budget Office score yesterday. There's a lot of hesitation to include state waivers that allow states to opt out of the Affordable Care Act ban on charging sick people higher premiums, and the Medicaid per-person funding growth rate debate is still unresolved.

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What CBO says about how AHCA will impact premiums

(J. Scott Applewhite / AP)

Most Republicans have one goal in repealing and replacing the Affordable Care Act: bring down premiums. So how did they do? The CBO verdict on the American Health Care Act is mixed: average individual market premiums would go down, and young and healthy people would be better off, but sick people could end up paying drastically more than they do under the ACA. Some would be priced out of the market.

What Republicans are saying: They're happy with the overall premium reductions. "This CBO report again confirms that the American Health Care Act achieves our mission: lowering premiums and lowering the deficit," House Speaker Paul Ryan said in a statement.

What's changed since the last CBO report: The biggest thing is that the House added state waivers to the bill, which would allow states to opt out of the ACA's essential health benefits and the requirement that sick people be charged the same premiums as healthy people. Whether states take those waivers has a big impact on whose premiums increase or decrease, and by how much.

In the short term, before most of the House bill provisions take effect, CBO estimates premiums will rise by 20 percent in 2018, and by another 5 percent in 2019. But they'd decrease after that — with some really big exceptions.

How waivers impact premiums: CBO divided states into three different categories:

  • States that don't take waivers: This is about half the population, and CBO estimates premiums in the individual market would decrease by 4 percent for these people, on average. But since the House bill allows insurers to charge older people more than the ACA does, premiums would be substantially reduced for younger people and would rise for older people.
  • States that use the waivers to make modest changes to ACA regulations: These states, which contain about a third of the population, would see bigger premium reductions. CBO estimates that premiums would be 20 percent less in 2026 than under current law, "primarily because, on average, insurance policies would provide fewer benefits." Again, younger people would benefit more than older people.
  • States that use waivers to make substantial changes to ACA regulations: This group contains about one-sixth of the population. Premiums would be lower than under current law, but people with pre-existing conditions "would face extremely high premiums." Premium variation would be very large.
  • It's not just premiums: People who live in states that take waivers could also see substantial rises in their out-of-pocket costs, as less benefits may be covered.
CBO also predicted how premiums would vary with age and income compared to under the ACA:
  • Older, lower-income people would pay "much larger" premiums.
  • Younger, lower-income people would pay about the same or smaller premiums.
  • Higher-income people of most ages would pay lower premiums, on average.
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One thing that won't change with GOP health bill: Medicaid coverage losses

(J. Scott Applewhite / AP)

There's a lot of uncertainty about how the Congressional Budget Office will estimate the costs of the GOP health care bill the House passed earlier this month. But one thing that's almost certain: It won't change its estimate that 14 million people will lose their Medicaid coverage.

That's because the House didn't change the bill's Medicaid provisions since CBO analyzed an earlier version of the bill. It makes significant cuts to the program, which will knock millions of people off their coverage. It then pairs these cuts with tax credits for those on the individual market, which fall well short of what very low-income people need to afford insurance, experts say.

What we're watching: Whether the Senate shores up the tax credits enough to put coverage within reach of people near the poverty line and helps with their other costs. If it doesn't, coverage will remain out of reach for the poor.

The House made other changes to the bill, including state waivers that could affect private health insurance. But the two main reasons for the Medicaid coverage losses haven't changed: The bill phases out the Affordable Care Act's expansion of the program, and it limits how much federal funding each enrollee gets.

And because the bill's tax credits wouldn't adjust for income, "there's just no way most people at or near poverty now eligible for Medicaid could afford to buy even a high deductible plan in the individual market," Larry Levitt, vice president of the Kaiser Family Foundation, told me.

What you need to know:

  • Both CBO and Medicaid experts predict that many states that expanded Medicaid — if not most — would drop the expansion of the program, because they wouldn't be able to afford it after federal funds are scaled back.
  • If that happens, the best option for people who just gained Medicaid coverage would be the individual market, where tax credits are offered based on age and vary between $2,000 and $4,000.
  • The House bill does not provide any kind of help for deductibles or out-of-pocket costs for low-income people, like the ACA does.
  • A $130 billion fund might help states reduce premiums, but probably not enough. And most of the money probably would be used to help sick people, not low-income people.
Here's an example, per the Brooking Institution's Matthew Fiedler:
  • A 45-year-old at 75 percent of the poverty line — currently eligible for Medicaid in an expansion state — would make around $9,500 in 2020.
  • An average "silver" plan, which is often used as a benchmark, would likely cost around $5,500 by 2020. The House bill's tax credit would cover $3,000 of this.
  • So this person would still be on the hook for $2,500 of the premium, which is more than a quarter of his or her income.
  • "Few would purchase insurance under such conditions," Fiedler told me.
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FDA to take new "forceful" steps on opioid abuse

(J. Scott Applewhite / AP)

The newly-confirmed FDA administrator, Scott Gottlieb, outlined a list of new steps the agency will take to crack down on opioid misuse and abuse in a blog post on Tuesday. Many people addicted to opioids first began abusing prescription painkillers, which are regulated by the agency.

He's creating a new steering committee to "explore and develop additional tools or strategies." In his post, Gottlieb outlined several questions he's asked the committee to answer:

  • Should the agency require mandatory opioid education for health care professionals?
  • Should the agency create new regulations around how many opioid pills are prescribed for specific medical conditions? (This would, for example, keep someone from being prescribed 30 pills when they only need two or three.)
  • Does the FDA have an adequate framework during the drug approval process for considering the risk of opioids?
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Funding insurer subsidies isn't going to be easy for Congress

(J. Scott Applewhite / AP)

Complex Senate rules are adding another snag to the debate over Affordable Care Act insurer subsidies. While insurers are begging Congress to fund them, the Senate can't just fold the subsidies as written in the ACA into its health care legislation without breaking the rules, GOP aides tell me.

That's because the Senate is trying to pass its bill through "reconciliation," which requires every provision to have an impact on the budget. Current spending projections assume the subsidies are being paid, so simply writing a law saying "Congress approves these payments" doesn't spend or save money. Thus, it can't be included in reconciliation.

Why this matters: It means that to make the payments under the reconciliation bill, as opposed to in separate legislation, Republicans would have to tinker with the payments to make them cost something or save money.

The stakes: Insurers say that without the subsidies — which help low-income people pay their out-of-pocket health care costs — they'll have to either drastically raise premiums or pull out of exchanges. Plans must decide whether to participate in federal exchanges in 2018 by June 21.

The conflict: Even if Republicans try to handle the payments in the reconciliation bill, it creates more potential for trouble between moderates and conservatives.

Conservatives have very little sympathy for insurers, and President Trump has said many times that if the subsidies go unfunded it forces Democrats to the negotiating table on health reform. But moderates are reluctant to cause chaos in the marketplaces, especially because there is ample reason to think Republicans would be blamed.

"We have the same conundrum on including it and alienating conservatives, or not including it and alienating insurance companies," a senior GOP aide told me. "I think at this point the goal would be to pair [the subsides] with some comparable policy reform."

The aide said, under this plan, the payments would likely be made for 2018 and 2019 plan years, saving money over ten years. Currently the subsidies are permanent spending and would be made every year.

Another wrinkle: The House Republican lawsuit over the legality of the subsidies was delayed for 90 days on Monday. While the Senate hopes to pass legislation before then, if something unpredictable happens in the case before the Senate acts — like the parties settle, or the administration drops the case — it could change the constraints members are working within. That could send them back to the drawing board.

The other options: Congress could just pass separate legislation funding the subsidies, subject to the regular 60-vote Senate threshold. But this seems unlikely right now, as it'd probably be seen by Republicans as supporting the ACA without attaching conservative reforms.

Congress could also deal with the subsidies through the normal appropriations process, but that could be too slow for insurers.

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Insurer subsidy lawsuit delayed, again

(J. Scott Applewhite / AP)

The Trump administration and the House have officially asked to delay, once again, a decision on how to resolve a court case challenging the legality of Affordable Care Act insurer subsidies. Here's the motion.

Key quote: "The parties continue to discuss measures that would obviate the need for judicial determination of this appeal, including potential legislative action."

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House and Trump administration to delay insurer subsidy case

(Atef Safadi / EPA Pool via AP)

The House and the Trump administration will seek an additional 90 days to resolve a pending court case over the legality of Affordable Care Act insurer subsidies, the Washington Examiner and CNBC report.

While the subsidies may continue to flow to plans operating on exchanges, the failure to reach a decision doesn't give insurers the certainty they're looking for. Plans must decide whether to participate in federal exchanges by June 21. If they don't get a guarantee that they'll keep receiving the subsidies, plans will likely drastically raise premiums or pull out of exchanges.

The Examiner reports the House and the White House are working on a plan to ensure the subsidies continue going to insurers, who pass them on to low-income enrollees.

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Medicaid cost increases by state, under the AHCA

The House health care bill would require many states that expanded Medicaid under the Affordable Care Act to pay much more for their newly eligible enrollees beginning in 2020. Here's what it would look like, based on projections from Republican Sen. Bill Cassidy's office:

Data: Government Accountability Office data analyzed by Sen. Bill Cassidy's office; Table: Andrew Witherspoon / Axios

Why states would have to spend so much more:

  • For newly eligible people who sign up before 2020, the federal government will keep paying for 90 percent of their costs — the higher matching rate under the Affordable Care Act.
  • But if they sign up starting in 2020, they only get the state's regular matching rate. In California, for example, this is 50 percent.
  • So the state goes from paying 10 percent of that person's costs under the ACA to paying 50 percent of his or her costs.
  • Massachusetts, Vermont and Montana also expanded Medicaid, but they've been left off of this list. Massachusetts and Vermont already had generous state Medicaid laws, so the ACA treated them differently. Montana expanded late, so data was unavailable.
  • These projections are based on 2016 spending. They don't account for variables like changes in the population or increased medical spending.
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Trump doesn't want to fund Affordable Care Act insurer subsidies

(Susan Walsh / AP)

President Trump has told advisers he wants to stop paying Affordable Care Act insurer subsidies, Politico reports. Without funding from the administration, exchanges could fall into chaos as insurers raise premiums or pull out of the markets. A lawsuit, brought by the House against the Obama administration, over the legality of the payments is currently pending.

Trump has said he thinks ending the payments will force Democrats to negotiate an ACA replacement. But some of his aides are worried Republicans would be blamed for intense market instability, as insurers may pull out or drastically raise premiums in response to not being paid.

What we're watching: The administration and the House are due for a check-in on the lawsuit on Monday. The case could continue to be delayed and appealed, or the administration could drop the case — meaning funding would stop.