Last month, after a YEARS-LONG delay, House or Representatives’ Speaker Paul Ryan and his Republican majority colleagues FINALLY released their “repeal and replace” plan for health care reform, should they maintain control of the House in this fall’s elections along with their Senate colleagues, and a Republican be elected President.  Their plan, dubbed “A Better Way”, would essentially return the nation to pre-Affordable Care Act days, while moving in additional conservative, market-driven/oriented directions, and giving private insurance much more hegemony and free rein.

Much of the document is nothing but political rhetoric and “Obamacare bashing”, offering few policy specifics.  Here’s the main elements:

General Insurance Reforms:

• Allow Insurers to offer plans across state lines.
• Promote “health savings accounts” (HSAs) and “consumer-directed” plans.
• Return health insurance regulation to the states, repealing the role of federal government.
• Establish (undefined) “State Innovation Grants” to lower premium costs and/or number of uninsured.

Individual Market Reforms:

Repeal the Affordable Care Act but…

• Allow young adults to stay on their parents’ plan
• Prohibit insurers from charging higher premiums to those with pre-existing conditions
• Prohibit insurers from dropping coverage for people who get sick
• Continue bans on lifetime coverage limits
• Eliminate the “individual mandate” tax penalty
• Eliminate state-based and federal “public” health insurance exchanges/marketplaces, along with the advanced premium tax credits (APTCs) to help the uninsured purchase insurance. Instead provide a fixed/flat tax credit to everyone in the individual market, adjusted by age, who would buy coverage through “private exchanges”.
• Prohibit insurers from charging higher rates to people with pre-existing conditions provided they keep continuous coverage.
• Provide a one-time open enrollment period for the uninsured regardless of health history.
• Establish separate state-based high-risk insurance pools for people with pre-existing conditions, for people who have breaks in coverage.
• Allow insurers to charge more to older people for the same plan/policy, beyond the current ACA standard of 3:1 ratio. Standard range would be 5:1 with state flexibility to go higher or lower.
• Unclear: What happens to 20M people currently covered under the new ACA plans?

Employer-Sponsored Coverage Reforms:

• End the “employer mandate” tax penalty.
• Cap the tax preference and tax deduction for employer-sponsored coverage.
• Allow employers to reward employees who participate in wellness programs.
• Allow small businesses and individuals to join together in “association” health plans.
• Allow small employers who self-insure to buy private “stop-loss” coverage.

Medicare Reforms:

• Raise eligibility age to 67 (matching Social Security.)
• Transform Medicare from a “guaranteed benefit” to a “defined contribution”/”premium support” program, with lower premiums for sicker people, lower out-of-pocket limits for low-income people, and higher premiums for wealthier beneficiaries.
• Create regional “Medicare Compare” websites/exchanges to list private Medicare plans and traditional Medicare.
• Combine Medicare Parts A and B, with a unified deductible, and a maximum annual out-of-pocket cost cap.
• Combine all four current Medicare Savings Plans (“MSPs”) into one program with a uniform asset test, to be run/set by states.
• Eliminates the new ACA-authorized “Independent Payment Advisory Board” (not yet implemented), and new the Center for Medicare and Medicaid Innovation.
• End mandatory cuts in subsidies to private Medicare Advantage plans.
• Allow private Medicare Advantage plans greater flexibility to offer “value-based” benefit designs.
• End “first dollar coverage” for private Medicare Supplemental (“Medigap”) plans.
• Allow physicians to enter into private financial contracts with Medicare patients for selected medical services covered by Medicare, but outside of Medicare per se.
• Repeal Medicare Disproportionate Share (“DSH”) cuts to hospitals for 2018-2019.

Medicaid Reforms:

• Transform Medicaid into a block grant program to states. States could choose either a “per-capita cap” or straight block grant.
• Eliminate many coverage requirements for state Medicaid programs.
• Allow states to create incentives for various healthier and personal behaviors.
• Repeal Medicaid Disproportionate Share (“DSH”) cuts for 2018-2020.

Health Insurance Tax Reforms:

Repeals new ACA funding streams:

• Excise (“Cadillac”) tax on high-cost, employer-sponsored/union health plans
• Increased Medicare taxes on high-income taxpayers, including investment income
• Penalties for non-qualified distributions from HSAs
• “Windfall profits” taxes on insurers, drug makers, and medical device manufacturers

Other Reforms:

• Combine Medicare and Medicaid “Disproportionate Share” (DSH) funds into one pool/program starting in 2021.
• Cap medical malpractice awards.
• Codify the anti-choice “Hyde Amendment” and “conscience clauses” for providers.
• Allow physician-owned hospitals.
• Reduce regulation of NIH research.
• Promote “personalized medicine”.
• Modernize clinical trials and reduce red tape.
• Reduce regulation of medical app development.
• Facilitate repurposing of drugs for patients with rare diseases.
• Reduce regulation on development of electronic health records.

Summary: http://abetterway.speaker.gov/_assets/pdf/ABetterWay-HealthCare-Snapshot.pdf

Full document: http://abetterway.speaker.gov/_assets/pdf/ABetterWay-HealthCare-PolicyPaper.pdf

As this year’s state legislative session drew to a close late last month, several bills important to consumer health advocates and our allies advanced: some to Governor Cuomo’s desk for signing or veto, others to firmer footing for next year’s session.  Depending on how this fall’s elections turn out will determine prospects for these latter set of bills come 2017.

Things started off well with the overwhelming passage on June 1st, for the second year in a row, of the New York Health Act (A.5062-A, Gottfried) by the New York State Assembly, by an 86 to 53 vote.  The bill would create a fully-public universal health care program covering all New York residents.   While New York’s uninsurance rate has dropped to less than 5% under the Affordable Care Act (ACA), we still need to cover those for whom the law offers no options.  This bill would draw on provisions of the ACA which allow states to move forward beyond and building upon the ACA, including implementing so-called “single-payer” systems, as embodied in this bill.  The Campaign to New York Health has been the lead coalition promoting it.

Next up was the Safe Staffing and Quality Care Act (A.8580-A, Gunther), which overwhelmingly passed the NYS Assembly on June 14 by a vote of 103 to 31. This bill sets minimum nurse staffing ratios in hospitals and nursing homes, by department. Nurse are WAY overworked and overburdened in many of these settings, and find it very challenging to provide quality, timely care to their patients. This bill helps remedy this crisis.  A similar law in effect in California for over a decade now has significantly improved patient care, the working conditions of nurses, AND saved money for hospitals and nursing homes.  The NY Campaign for Patient Safety, led by the NYS Nurses Association and the Communications Workers of America, has been the coalition promoting the bill.

In the literal final hours of the session, three bills actually moved to enactment, for signature by the governor:

• Enhanced Safety Net Hospitals Act (S6948-A/Hannon, A9476-A/Gottfried) – This bill raises the Medicaid reimbursement rate to hospitals for whom their over 50% or their patients are either uninsured and/or covered by Medicaid. These are hospitals that are suffering because of federal funding cutbacks for indigent care. This bill was promoted by the Save Our Safety Net Campaign and various public sector unions, and came out of nowhere in about 3 months, highly unusual for the legislative process.

• Advanced Home Health Aide Act (S.8110/LaValle, A.10707/Glick) – This bill creates a new category of nursing professional to provide certain services in home and community-based settings so that patients with complex health needs can live at home/in the community if they choose, rather than be forced only to live in skilled nursing facilities/nursing homes.  This bill was promoted by Medicaid Matters New York, the New York Independent Association for Independent Living, and various senior citizen and disability rights groups after a multi-year effort.

• Expedited Utilization Review for Prescription Drugs Act (S,3419/Young, A.2834-D/Titone) – This allows physicians to request overrides of insurers’ “step therapy” and “fail first” limitations on certain drugs on a case-by-case basis when needed.  The bill was promoted by New Yorkers for Accessible Health Coverage and their allies after a multi-year effort. 

Unfortunately, two other bills were “left on the table”:

• Comprehensive Contraceptive Coverage Act (S.6013/Bonacic, A.8135-B/Cahill) – would mandate that health insurers cover all forms of FDA-approved contraception. It passed the Assembly back in January and has been stuck in the Senate Insurance Committee since.

• “Lavern’s Law” (S.6596-B/DeFrancisco, A.10719-A/Weinstein) – would to change the filing deadline for medical negligence/malpractice suits from the physician’s date of diagnosis of a given condition to the patient’s date of notification. It passed the Assembly in 2015 and is now before the Judiciary Committees in both chambers.