Immigration and Health Care Under the Trump Administration [from Health Affairs Blog]

PHLW is back with this post by our own Wendy E. Parmet on the Health Affairs Blog.  The piece about the current state of immigration and health care comes out of her recent presentation at the Harvard Law School Petrie-Flom Center Sixth Annual Health Law Year in P/Review in December 2016.

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Immigration and Health Care Under the Trump Administration

by Wendy E. Parmet

Non-citizen immigrants are the canaries in the health care coal mine. Disproportionately poor, non-white, and non-English speaking, and without access to the franchise, they are among the most vulnerable groups in the United States. Consequently, they are often the first to experience the gaps, inefficiencies, and conflicts in our health care system. Meanwhile, anti-immigrant sentiment often spills into health policy debates, as was evident in 2009 when opponents of the bill that became the Affordable Care Act(ACA) focused their opposition on the erroneous claim that it would cover undocumented immigrants. It is therefore not surprising that the first year of the Trump administration, which has focused its domestic agenda on restricting immigration and repealing the ACA, has proven especially perilous for immigrants who need health care.

As a group, immigrants tend to be healthier than the native-born population. They are also far less likely to have insurance. In 2015, for example, 18 percent of lawfully present nonelderly adult immigrants, and 42 percent of undocumented immigrants were uninsured, compared to only 11 percent of United States citizens. Immigrants’ low insurance rate is partly due to the fact that they disproportionately work in sectors of the economy in which employer-sponsored insurance is uncommon. But the law also plays a significant role. Even before the Trump administration took office, immigrants faced an array of legal barriers to obtaining health insurance. Most importantly, the 1996 Personal Responsibility and Work Opportunity Reconciliation Act (PROWRA) prohibited undocumented immigrants from accessing most federally-funded insurance programs (including Medicaid, Medicare and Children’s Health Insurance Program (CHIP)). PRWORA also barred most authorized immigrants (except refugees) from benefiting from federally-funded programs for five years after obtaining legal status. And although the ACA made it easier for many documented immigrants to gain coverage, it left PROWRA in place. The ACA also limited participation in the exchanges to immigrants who are “lawfully present,” a category that the Obama administration decided did not include the approximately 800,000 young adults who participated in the Deferred Action for Childhood Arrivals (DACA) program. 

The Trump administration’s policies threaten to swell the number of uninsured immigrants, and deter those who have insurance from accessing needed care. For example, several of last year’s Republican proposals to repeal and replace the ACA included specific provisions to bar further classes of immigrants from purchasing insurance on the exchanges, even when they used their own money. Other proposals would have allowed states to deny Medicaid reimbursement for services rendered to eligible non-citizens prior to documentation of their immigration status. In addition, because immigrants tend to have lower incomes than the native-born population and are less likely to have employer-provided health insurance, they would have been disproportionately harmed by efforts to repeal the Medicaid expansion.

Read the entire piece on Health Affairs here: Immigration and Health Care Under the Trump Administration

Why is Congress not prioritizing health care for children and other vulnerable populations?

By Jennifer Lea Huer

Back in September of this year, Congress was faced with the decision of whether or not to renew funding for both the Children’s Health Insurance Program (CHIP) and the Community Health Center Fund. Both sources of funding expired on October 1, 2017. As of the date of this post, 68 days have passed since Congress failed to renew funding for these crucial programs. Much has been written about the imminent need to reauthorize CHIP funding; states are already warning their residents that funding is running low and decisions about cutting coverage may soon follow. In addition to the estimated 9 million children in danger of losing coverage if CHIP funding is not renewed, recent studies estimate that millions more people could lose access to care if Congress does not take concrete steps to reauthorize funding for community health centers.

The federal government formalized its commitment to community health centers (CHCs) back in 1965, when it established the Health Center Program – a program that champions the development and capacity of CHCs, especially in the provision of care for millions of our country’s most vulnerable patients. The Patient Protection and Affordable Care Act (ACA) reiterated the US commitment to CHC growth and funding by establishing the Community Health Center Fund. The ACA authorized five years of funding, a total of about $7 billion, for CHCs. This funding meant that every state in the United States, including the District of Columbia, could have at least one CHC.  Federal funding also led to implementation of primary care programs, as well as behavioral health programs, and specific programs focused on special populations (e.g., veterans, children, chronically ill, homeless). Upon its expiration in 2015, Congress extended community health center funding for an additional two years, which, as mentioned, expired on October 1st.

Congress’ inaction is of the utmost concern, because community health centers are essential components of the American health care system, providing primary care services to more than 27 million people each year. One in 12 patients are served by a federally-funded CHC. Twenty-five percent of rural Americans receive their primary care from a CHC. An overwhelming percentage of CHC patients represent racial and ethnic minority groups. As other settings within the health care system continue to grow and cost more money, CHCs find themselves struggling to provide care to increasingly larger volume of patients, particularly for patients who would otherwise not have access to appropriate and cost-effective primary and ambulatory care services.

CHCs are known to provide high quality care and have a low per patient cost, but because the majority of their patients are under- or uninsured, CHCs heavily rely on federal support to maintain financial stability. Federal support for CHCs comes in the form of grants – which account for 70% of CHC funding. And end to the health center program means that CHCs will lose 70% of their funding, which will result in what experts have termed a “funding cliff.” This situation is especially dire for states that chose not to expand Medicaid; CHCs have even higher numbers of uninsured patients in these states (when CHCs cannot rely on Medicaid payments for otherwise reimbursable services, they must utilize more of their federal grant dollars to provide direct care, rather than using that grant funding to expand capacity for care delivery and specialized programs).  Experts are also forecasting that beyond stress to the health care system, this significant loss of funding will have detrimental effects in other sectors of our economy, including employment and state tax revenue.

Interestingly, both the House and the Senate have introduced bills that would extend funding for CHCs. But while both chambers have referred the Community Health Investment, Modernization, and Excellence Act of 2017 to sub-committees for review, the bills have stalled, with no further action occurring since September.

Here in Massachusetts, CHCs are trying not to panic, but many are worried that they will need to cut staff, clinic hours, and in the worst cases, shut down their facilities. The CHC funding cliff would result in Massachusetts CHCs losing $196 million in funding, which would impact hiring of new staff, continuation of much needed expansions (facility and programmatic), and, most importantly, it would mean that more than 141,000 residents could go without health care.

As the Trump Administration continues to aggressively degrade the integrity of the ACA and health care in the United States, CHCs will find themselves pressured to rise to the challenge of filling gaps in care delivery and cost containment. The CHIME Act indicates bipartisan recognition and support for solving the impending funding crisis, but Congress has not stopped internal squabbling long enough to focus on acting in the best interest of its constituents. It’s time members of Congress prioritize serving those who need them most and move to immediately reauthorize funding for the Community Health Center Fund.

Republicans Failed Because They Have No Idea What Kind of Health Care They Actually Want

by Robert I. Field

Not so long ago, much of the Republican Party stood united in a vision for health care. For 20 years, Party leaders from across the political spectrum coalesced around elements of a plan that would use the private market to broadly expand coverage.

The plan looked something like this. All Americans would be subject to a mandate to obtain health insurance for themselves and their families or pay a penalty along with their taxes. Most employers would be mandated to offer insurance to their workers. Those without access to employer-sponsored coverage would buy policies on an exchange directly from insurance companies, and insurers would be required to offer coverage regardless of an applicant’s health status. Subsidies would be available for those with low incomes, and those who were very poor would receive coverage under an expanded Medicaid program.

Sound familiar? It is the essence of Romneycare, the health reform plan enacted in Massachusetts in 2006 with the support of Republican governor Mitt Romney.

Romneycare emerged after more than 15 years of Republican efforts to implement such a system. It was originally devised by the Heritage Foundation, a conservative think-tank, in 1989. The concept was supported by 21 Republican senators in 1993, including many moderates, when it formed the basis of the Health Equity and Access Reform Today Act, an alternative to the Clinton plan that was then being debated in Congress.

Heritage encouraged the enactment of Romneycare in 2006 and subsequently touted the plan as a workable solution that should be implemented across the country.

And the concept formed the basis of a plan proposed in 2009 by two conservative Republicans, Representative Paul Ryan and Senator Tom Coburn, the Patients’ Choice Act.

Of course, the Republican market-based plan is also the core of the Affordable Care Act.

What happened when Democrats signed on to the approach? The Republican consensus immediately evaporated. Even Heritage turned against its own handiwork. As soon as the ACA was enacted in 2010, Republicans in Congress announced unbending opposition and began an unrelenting effort to “repeal and replace.”

But seven years later, that promise remains little more than a slogan. Republicans voted more than 60 times to repeal all or part of the ACA while Obama was president, knowing their votes were merely symbolic, since he was certain to veto any legislation that emerged.

And now that they control of both houses of Congress and the White House and have the chance to actually bring a plan to fruition, they can’t figure out what they want.

Republican conservatives want to eliminate any trace of the ACA, even if it means denying lifesaving health care to tens of millions of Americans. Moderates want to insure that whatever form a replacement takes, the ACA’s coverage gains are largely maintained. The Republican health care bill that failed in the Senate this week, the Better Care Reconciliation Act, meets the goals of neither wing.

President Trump can’t seem to decide what he wants, either.  He promised at the start of the presidential campaign that he would not reduce Medicaid spending, but his budget proposal includes major cuts.

The only unifying theme in Republican positions today is a desire to dismantle anything created by President Obama and his Democratic colleagues, even programs based largely on their own principles. That is hardly a vision for constructive public policy.

Crafting a complex government program requires painstaking work, including the arduous task of consensus building. It is not accomplished by hatching a plan through the secret deliberations of 13 senators, as Senate Republicans did in crafting the BCRA, and then rushing it to a vote.

But the laborious work of building programs and forging consensus is the essence of governing. That’s a lesson members of the Republican leadership do not seem to have learned. With their failure, at least so far, to either repeal or replace the ACA, they are now seeing the results.

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Previously posted on the Health Cents blog on Philly.com.

Can Trump Simply Stop Paying Subsidies to Insurance Companies?

By Elisabeth J. Ryan

In recent days, President Donald Trump announced, via Twitter, that "If a new HealthCare Bill is not approved quickly, BAILOUTS for Insurance Companies and BAILOUTS for Members of Congress will end very soon!"  He was presumably referring first to cost-sharing reduction subsidy payments to insurance companies required by the Affordable Care Act and, second, to the fact that members of Congress and their staff are required to buy health insurance on the ACA market instead of being allowed on the federal employee health plan.  However, unlike most people who purchase insurance via the marketplace, Congressional staffers still receive an employer subsidy.  Ending subsidy payments to insurance companies could be catastrophic to the market - so can Trump simply stop paying them?

Section 1402 of the Affordable Care Act mandates that insurers reduce the amount of cost-sharing that individuals are responsible for; in turn, the government pays the insurer subsidies in order to make up for the discounts passed onto consumers.  However, the House of Representatives sued the then-Obama administration in 2014, claiming that such subsidy payments were illegal and unconstitutional because Congress never made specific appropriations for them.  In May 2016, the federal district court decided in favor of the House , finding that the executive branch (the Department of Health and Human Services in this case) making payments to insurers in the absence of a specific Congressional appropriation to do so is illegal and must cease.  The judge stayed her order, however, pending appeal (or, as the Republicans hoped, a change in the law entirely).  This has left the payments in a sort of limbo - the Obama administration continued to pay the subsidies and, thus far, so has the Trump administration.  But he has been hinting for months that wants to stop that practice; in response, numerous state Attorneys General filed a motion to intervene in the case, fearing that Trump would drop the appeal and allow the order of non-payment to stand.  On August 1, the court granted the motion, ensuring that the appeal will at least continue.  A crucial legal questions remains: even if the district court's order is overturned, would that simply allow the administration to continue making payments or is there some mechanism to compel the payments?

The House has relied on the fact that a specific appropriation exists for section 1401 of the ACA, which grants tax credits to some individuals to offset their insurance purchase costs.  And because section 1402 (the insurance subsidies) is not specified in that or any other appropriation, the court agreed that no such appropriation exists.  However, as the Obama administration and now the state AGs argue, the 1401 appropriation also covers 1402; that is, indeed, the fund used currently to pay the subsidies. 

If the government stops paying the subsidies, there is little question that the insurance market will destabilize quickly and critically.  While the details may vary based on state law, insurers could drop participation in the marketplace for the rest of 2017, could choose not to be part of the marketplace in 2018 at all, and would certainly raise premium costs for consumers, perhaps as much as 20%.

If Trump does announce that he will cut off payment of the subsidies to the insurance companies – the next payment is due on August 21 – states, insurance companies, and perhaps even consumers would likely sue immediately.  Indeed, some states may be preparing to file an action before he even announces a decision.  As California Attorney General Xavier Becerra has said, “We’re not going to wait to find out what Donald Trump wants to do.  My team is ready to defend these subsidies in court.”  AG Becerra has characterized the President’s threats to end the subsidies as “extortionist tactics.”  

Of course, Congress could remove the uncertainty (at least temporarily) about whether the subsidy payments will continue by passing a specific appropriation and may be attempting a bipartisan solution to do so.  But unless and until that happens, the insurance marketplace - and the healthcare plans of millions of consumers - remains in a precarious position.