The debate about U.S. health care reform and the repeal and replacement of the Affordable Care Act (ACA) has once again “risen from the dead” in the form of the Graham-Cassidy bill in the Senate. Amazingly, instead of getting better, each attempt to repeal and replace the ACA appears to be getting worse.
With any health care reform, the primary points of emphasis should be: 1. Improved access to health care for all. 2. Improved quality of the care delivered. 3. Lower health care costs for all stakeholders. Unfortunately, the Graham-Cassidy bill as proposed provides no assurance that any of these aims will be attained.
While the ACA is far from perfect, it did initiate some much-needed reform in the way US healthcare is delivered. Many of these gains would likely suffer if the Graham-Cassidy bill were passed. Looking at the bill in summary:
• It would eliminate the federal insurance exchange and subsidies and tax credits under the ACA that help people afford insurance. All federal subsidies would end in 2026.
• It would eliminate penalties for not obtaining health care insurance, which could shrink the pool of insured, which would likely contribute to increased premiums.
• Instead of subsidies it would provide fixed state block grants but does not require states to use these block grants to help lower income people buy insurance coverage.
• Under the ACA, insurance plans must provide defined essential healthcare benefits and charge everyone the same premium regardless of pre-existing conditions. Graham-Cassidy would allow individual states to waive this requirement, which would create serious inequalities in coverage and once again discriminate against people with pre-existing conditions making healthcare for them unaffordable. Changing the essential health benefits (EHBs) requirements would also undermine the ban on lifetime and annual caps that apply only to EHBs. These changes could render patient protections meaningless.
• It would drastically change the Medicaid program by ending Medicaid expansion entirely in 2020 and cap funding overall and it would redistribute the funds that are being used to support the current Medicaid expansion. It would attempt to equalize payments among states, which would penalize states that expanded Medicaid and reward states that did not.
• It provides no dedicated funding for substance abuse treatment which given the current public crisis around opioid use is problematic.
All of this is happening in the most partisan manner imaginable as a “Republican Only” initiative in the Senate. Under the Senate process of “budget reconciliation” floor debate on bills is limited to 20 hours and there is no use of a filibuster to block legislation. Also under budget reconciliation the Senate would only need 50 votes to pass the bill until Sept. 30, when they would once again need 60 votes.
As a result, there is a rush to jam this bill through before Sept. 30, with none of the due consideration in committees and floor debate that something this important deserves. And, perhaps most disconcerting, is the fact that the Congressional Budget Office will not have time to score the bill in terms of its impact on coverage for Americans or how premiums will be affected.
Something as important as health care deserves a much more measured approach and careful thought than the current process, and it must be a bi-partisan approach that works for all. The U.S. currently spends more than 18 percent of our gross domestic product on health care, which is over $3 trillion annually, yet we rank 37th in health outcomes worldwide and we still have over 30 million people without coverage. We can and must do better, but Graham-Cassidy is not the answer.
James A Jorgenson, R.Ph., M.S., FASHP, Sandy, is CEO at Visante, a multi-national health care consulting firm supporting both hospitals and health systems as well as the insurance and payer community.