Conservatives Split From GOP Leaders Over Quick Obamacare Repeal

GOP lawmakers on Capitol Hill are committed to using a budget tool called reconciliation to send a bill repealing Obamacare to President-elect Donald Trump’s desk.

Though Republicans are settled on getting rid of the Affordable Care Act, fault lines have emerged between GOP lawmakers who disagree on when, exactly, the health care law should be repealed and, to a lesser extent, which Obamacare provisions to include in the reconciliation bill.

On one side are Republicans like Sens. Orrin Hatch of Utah and Susan Collins of Maine, who have said they would like to see enactment of Obamacare’s repeal delayed until 2019 or beyond, which would give the GOP-led Congress time to craft, pass, and implement a replacement for the health care law.

“I’d like to do it tomorrow, but reality is another matter sometimes,” Hatch, who chairs the Senate Finance Committee, told The Washington Post. “We have to live with the real world, and the real world right now is that the Democrats won’t help with anything.”

But opposite those Republicans are conservatives like Reps. Mark Walker and Mark Meadows, both from North Carolina, who want to see repeal enacted in the first few months of Trump’s administration.

“We need to show some urgency,” Walker told The Daily Signal. “I won’t put it in how many days, but over the first few months, the repeal needs to be enacted out of the gate.”

Unlike Walker, who will take over as chair of the Republican Study Committee next year, Meadows has mapped out a timeline to repeal the health care law within Congress’s first 100 days, then pass and implement a replacement over a span of roughly 17 months.

“We need to have a very aggressive timeline on repeal,” Meadows, who recently took over as chairman of the House Freedom Caucus, told The Daily Signal. “What I would be hopeful for is a replacement that would come shortly after that, but to combine the two would be a mistake in that it would slow down the repeal process.”

Republicans plan to use reconciliation—which allows a bill to pass the Senate with just 51 votes—to repeal Obamacare, and are looking to pass a reconciliation bill during the first days of the 115th Congress, which begins Jan. 3.

Though most agree that the dismantling of the 2010 health care law should come before Congress starts to tackle the proposal to replace Obamacare, others say that a delayed enactment for repeal occurring in 2019 or beyond would ease the transition for those currently enrolled in plans purchased on the exchanges.

Under Meadows’ timeline, leaders in the House and Senate would draft reconciliation instructions—which tell budget leaders what to include in the bill—and pass the legislation within their first 14 legislative days.

Repeal would then take place within the first 100 days, which Meadows said would provide insurers time to begin crafting plans for 2018 that aren’t required to adhere to the insurance mandates created by the Affordable Care Act.

Those regulations, opponents of the health care law say, caused the cost of premiums to rise.

Under Meadows’ plan, implementation of a replacement would happen over the span of roughly 17 to 18 months, which would allow the Trump administration to work through new regulations for the 2019 plan year.

“Adjusting in six months, that’s a herculean leap,” Meadows said. “Adjusting in a 17- to 18-month time frame is certainly something that all the insurance providers can do, and they’ve been asked to do much more in adjusting to the Affordable Care Act with less specificity coming from the Department of Health and Human Services.”

Already, Meadows said he is seeking input from at least two insurance providers on a viable plan to repeal and replace the law.

While the North Carolina Republican believes their contribution will present congressional leaders with a “compelling case” as to why the law needs to be rolled back quickly, he’s adamant that leaving it in place for even a few years will hurt consumers.

“A gradual wind down will still create perverted markets with regards to health insurance,” Meadows said. “I don’t know of any argument that would suggest that a three- to five-year wind down will make it less onerous on the American people.”

A Place to Start

Budget leaders and staff are already discussing what should be included in the reconciliation bill that would repeal Obamacare, and they’re using the legislation crafted in 2015 and subsequently passed by Congress as a blueprint.

That reconciliation bill repealed the individual and employer mandates, Medicaid expansion, and Cadillac and medical device taxes. The legislation also stripped the government of its authority to operate the federal and state-run exchanges, and lessened the fine for failing to comply with the mandates to $0, which was needed to abide by Senate rules.

Through that legislation, Republicans already charted a successful course for repealing Obamacare, one that received the stamp of approval from the Senate parliamentarian.

But both Walker and Meadows, along with Sen. Mike Lee, R-Utah, believe that the bill crafted next year should go further.

“That’s the minimum,” Walker said of the 2015 bill. “That needs to be the starting place, not the ending place.”

In an op-ed for National Review, Walker and Lee called for the next reconciliation bill to also repeal Obamacare’s insurance mandates, which include the essential health benefits requirement, the ban on limiting or denying coverage to consumers with pre-existing conditions, and the contraception mandate.

“When government bureaucrats and politicians decide that every insurance policy must cover free doctor visits and abortifacients, Americans who don’t need those options end up paying more for products they don’t want,” Walker and Lee wrote. “That’s great for the insurance companies, but not for taxpayers or consumers.”

Abortifacients are drugs that cause abortions.

There is skepticism as to whether a repeal of the insurance mandates would pass muster with the Senate parliamentarian, who has the authority to strike out parts of a reconciliation bill.

But the trio of Republicans believe that lawmakers should at least attempt to eliminate the mandates.

“To leave some of these aspects in place is not an excuse the American people are ready to accept,” Meadows said.

Dissent

Both Meadows and Walker told The Daily Signal that though they would like to see a reconciliation bill for next year go further than that passed in 2015, they would still support a bill that mirrors the one crafted more than one year ago.

But Sen. Rand Paul, R-Ky., is threatening the GOP’s ability to pass the budget resolution—one that would include the reconciliation instructions to repeal Obamacare.

In an op-ed in Time, Paul pledged to vote against the budget resolution.

“I will not vote for any budget that doesn’t have a plan to balance, regardless of what is attached to it, and I’m calling on other conservatives in the Senate to take the same stand,” the Kentucky Republican said.

Just 51 votes in the Senate are needed for the budget to pass, and Republicans hold 52 seats in the 115th Congress.

Democrats and independents hold a total of 48 seats, so if Paul and one other GOP senator decide not to support the fiscal roadmap, Vice President-elect Mike Pence would be the tiebreaker.

But waiting for Pence to vote would mean the bill repealing Obamacare couldn’t be voted on until after he and Trump are sworn into office on Jan. 20.

So far, it doesn’t appear that Paul has support from other conservatives.

Meadows and Walker said they support Paul’s calls for a balanced budget, but wouldn’t go so far as to oppose the budget resolution that would be the vehicle for Obamacare’s repeal.

“Am I with him in terms of believing that a debt ceiling increase and a future budget must balance and must be on a path to balancing? Without a doubt,” Meadows said, “so it may be more a tactical question of difference versus a strategic question that we differ on.”

Additionally, many conservatives in both chambers, including Lee, voted in support of the budget resolution for 2016 specifically because it instructed congressional leaders to draft a reconciliation bill repealing Obamacare.

The post Conservatives Split From GOP Leaders Over Quick Obamacare Repeal appeared first on The Daily Signal.

How States Can Shape Obamacare’s Replacement

As Republicans prepare to hammer out the details of a replacement for Obamacare, governors and state insurance commissioners are asking for a seat at the table.

Under the Affordable Care Act, much of the regulatory framework that in the past fell to states and their respective insurance commissioners was transferred to the federal government, which created blanket mandates for both consumers and insurers.

But as Republicans have begun discussions of repealing and replacing the Affordable Care Act—with action coming as early as January—states and their executive branches have the opportunity to help map out the future health insurance market.

“There’s going to be the opportunity to say we can actually start from scratch, but we’ve been in the mode of trying to work within the parameters of the immense amount of regulation under the Affordable Care Act that it’s difficult to switch gears and think about things in a whole new light,” Mia Heck, director of the health and human services task force at the American Legislative Exchange Council, or ALEC, told The Daily Signal.

“It’s a great problem to have, but it’s just a lot to think about,” Heck continued.

In recent years, policymakers have been dealing with “top-down framework” for the health care market, that being the Affordable Care Act, Heck said. But now that Republicans are gearing up to repeal the law and pass a replacement plan, there’s an opportunity for states—and ALEC—to have a seat at the table.

“We’re going to have the opportunity to talk about what would be best for states so they can increase competition and choice in their health care markets, which will result in lower costs and better quality of care,” Heck said. “It’s an exciting time in health care.”

Already, state executives are making it known that they want to play a visible role in shaping Obamacare’s replacement.

“Governors will be very, very active and engaged,” Frederick Isasi, who oversees health policy at the National Governors Association, told The Hill. “They really are one of the few groups who are, in this very tangible day-to-day way, are living the results of the policies.”

And congressional leaders are heeding their calls.

Last week, House Majority Leader Kevin McCarthy, along with the current chairs and incoming chairs of three House committees, sent a letter to governors and insurance commissioners asking for their help with crafting Obamacare’s replacement.

“Our values, based on the principles of federalism, drive a philosophy that states should have the freedom and flexibility to create options that are best for patients,” the lawmakers wrote. “Insurers should compete for consumer business and treat patients fairly. And Americans should have access to the best life-saving treatments in the world.

“Working as a team, with your help and creative ideas, we can achieve our mutual goal of putting patients first.”

Back to the States

Though GOP lawmakers are still in the process of mapping out their blueprint for Obamacare’s repeal and replacement, health policy experts say lawmakers in Washington need to eliminate the insurance regulations enacted at the federal level that the Affordable Care Act put in place.

“Historically, the regulation of health insurance has been left up to the states, so what the state of Vermont decides to do with health insurance regulations and benefits can be very different from what the state of Arizona decides,” Rea Hederman, executive vice president at the Buckeye Institute in Ohio, told The Daily Signal.

“What the Affordable Care Act did was wipe away decades of experience at the state level managing insurance,” he continued.

Among the insurance regulations included in the health care law was the essential health benefits package, a list of 10 services that all insurance plans were required to cover.

That measure, in particular, drove up the cost of health insurance, ALEC health care expert Heck said.

But if Congress follows through on its promise to repeal Obamacare, states and their insurance commissioners could once again manage their own insurance plans and regulations, Heck and Hederman agreed.

“[Congress] needs to return [to states] the traditional responsibility of determining what is the right plan for their citizens that states have always enjoyed,” Hederman said.

Like the essential health benefits package, the Affordable Care Act also changed the rating rules insurers were required to adhere to. The health care law prohibited insurers from limiting or denying coverage to those with pre-existing conditions and limited how much insurers could price premiums based on age.

But if states were given the authority to control insurance regulations, they could adjust their rating rules, Heck said.

“They’re going to have a lot to take into consideration,” she said of state lawmakers, “because it’s going to be a whole new opportunity to determine what their health insurance regulatory framework should look like.”

In addition to giving governors and insurance commissioners the authority to craft insurance regulations based on their own jurisdictions, an Obamacare repeal will allow states to implement their own Medicaid reforms.

Congress passed a bill earlier this year repealing key provisions of Obamacare, including the Medicaid expansion, and if a repeal bill passed in 2017 included a rollback of Medicaid expansion, states would then have more authority over the design of the program, Heck said.

Already, some state lawmakers are looking forward to changes to the Medicaid program.

Maine state Sen. Eric Brakey, a Republican who chairs the Health and Human Services Committee, said he would like to see Medicaid turned into block grants or allow beneficiaries to set up health savings accounts.

“Anything we can do to put the purchasing power back in the hands of the patient,” Brakey told The Daily Signal.

House Speaker Paul Ryan and House Budget Committee Chairman Tom Price, R-Ga., who President-elect Donald Trump nominated to serve as secretary of the Department of Health and Human Services, already advocate turning Medicaid into a state block grant program.

Health policy experts, meanwhile, say states should be encouraged to use existing and new waivers to change their Medicaid programs.

One such waiver, Section 1332, was implemented under the Affordable Care Act and exempts states from provisions of the health care law. States are then allowed to pursue new approaches to health care.

During debate over the waivers, the bipartisan National Governors Association encouraged the Obama administration to provide states with the “flexibility needed” to pursue them.

But late last year, the Department of Health and Human Services implemented strict regulations on proposals submitted by states, which limited their ability for reforms.

A second waiver, Section 1115, was implemented under the Social Security Act and allows states to use Medicaid dollars in ways not permitted under federal rules.

Under a Trump administration, health policy experts say they’d like to see more flexibility from the executive branch in terms of the reforms states can pursue using the waivers.

By using Section 1115 waivers, states could potentially implement work requirements for Medicaid recipients or ask them to pay premiums, Hederman said.

But by using a Section 1332 waiver, which Hederman said would need to be revamped, states could “regain control of their health insurance market from the federal government.”

“I’ve told state legislators they need to be ready. They need to be ready for repeal, and they need to be ready for a lot more flexibility with the Medicaid program,” Hederman said. “Take a look at using the 1115 and revamped 1332 waiver to maximum state freedom in the health care market.”

Though congressional leaders haven’t signaled whether they plan to include the Section 1332 waivers in an Obamacare replacement plan, McCarthy asked governors and insurance commissioners to gauge their interest in pursuing them next year.

Still, Republicans in Congress are continuing discussions over how to repeal Obamacare, and they haven’t yet presented a plan that would replace the law.

But McCarthy’s letter, coupled with the urging of the National Governors Association, suggests that states will play a greater role in mapping out the new proposal.

“The one-size-fits-all solution that the Affordable Care Act implemented has not worked,” Hederman said. “The evidence is in, and the [Affordable Care Act] did not work. Let’s give the insurance authority back to the states to best meet the needs of the population.”

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