Republican Senator Susan Collins criticizes secretive process of Senate health care replacement bill

WASHINGTON — Who's right — President Donald Trump and Sen. Bill Cassidy, or late-night host Jimmy Kimmel?

None has really captured the complexity of the debate over who might lose insurance protections in the latest Republican health care bill. But of the three, the TV guy is the hardest to refute.

Trump insists in a tweet that the bill covers pre-existing conditions, a point also made by Cassidy, a sponsor of the legislation. But there's a catch. It allows states to get a waiver from "Obamacare" requirements that insurers charge the same to people with health problems as they do to healthy people.

The potential result: unaffordable premiums for people in poor health.

Here's a look at Trump's assertion, the facts and the Kimmel-Cassidy feud:

TRUMP: "I would not sign Graham-Cassidy if it did not include coverage of pre-existing conditions. It does! A great Bill. Repeal & Replace."

THE FACTS: Such coverage may be included but it's far from assured.

The health care law enacted by President Barack Obama in 2010 offers two levels of protection for people with pre-existing conditions. The GOP bill would allow states to undermine one of them. That loophole could lead to policies priced out of reach.

To start with, "Obamacare" requires insurers to take all customers, regardless of health problems. On top of that, it prohibits insurers from charging more on account of medical conditions.

Under the GOP bill moving toward a Senate vote next week, insurers would still be required to accept people with pre-existing conditions. But here's where the catch comes in:

States could seek waivers that allow insurers to charge people more on account of health problems. That would allow insurers to offer lower-premium plans to healthier customers.

And states could also get waivers that allow insurers to tailor benefits so that people with costly conditions are discouraged from signing up. For example: plans that don't cover treatment for substance abuse problems.

"If I was a person with a pre-existing condition, I would say I don't have any guarantee of getting health insurance if the bill passes," said Gary Claxton of the nonpartisan Kaiser Family Foundation, an expert on the private health insurance system.

"Insurers can charge people with pre-existing conditions much higher rates, making it essentially a denial," added Claxton.

Dr. Michael Munger of Kansas City, Kansas, estimates that 4 in 10 of the patients in his family medicine practice have some sort of condition that could result in higher premiums.

"Individuals that I care for have had a previous cancer diagnosis, underlying diabetes complications, previous heart attacks and heart surgeries," he said. "I am very worried about affordable coverage. We have had a lot of gains and this is certainly something I don't want us to go backward on."

Munger is president of the American Academy of Family Physicians, which is among the major doctors' groups opposing the GOP legislation.

Supporters of the bill, named for its chief sponsors Sens. Lindsey Graham of South Carolina and Louisiana's Cassidy, point out that the legislative text says states seeking federal waivers must explain how they will "maintain access to adequate and affordable health insurance coverage for individuals with pre-existing conditions."

But Claxton says there's nothing in the text to define what "adequate and affordable" means and, as he reads it, it's unclear if the federal government would even have authority to deny a state waiver application. The bill also reduces federal money, adding to the pressures on states.

The health insurance industry is on record saying the bill would create problems by "pulling back on protections for pre-existing conditions," according to a letter to lawmakers from the trade group America's Health Insurance Plans.

Cassidy is in a public battle with TV host Kimmel about whether the bill meets the "Jimmy Kimmel test." That's a phrase coined by the senator this year after Kimmel gave a heartfelt account of how his infant son got surgery to correct a birth defect, and declared that all American families should have access to high-level care.

Kimmel says the senator should stop using his name. "This new bill actually does pass the Jimmy Kimmel test, but a different Jimmy Kimmel test," said Kimmel. "Your child with a pre-existing condition will get the care he needs if, and only if, his father is Jimmy Kimmel."

Cassidy says Kimmel doesn't understand the legislation.

Kimmel's critique goes to the core of the issue. But it's more nuanced than either he or Cassidy acknowledge, says insurance industry consultant and blogger Robert Laszewski. He points out that governors and legislatures would have to take action to weaken insurance protections guaranteed in federal law under Obama. Those state lawmakers would face pushback from consumers and medical groups, so it's not a given that such protections would be lost.

Nonetheless, Laszewski says Republicans have created a problem for their legislation.

"I think they made a huge mistake by leaving a crack open," said Laszewski. "And Jimmy Kimmel and the Democrats are going to try to drive a truck through it."

WASHINGTON — The collapse of the Republican effort to overhaul the health-care system and the resulting standoff in Washington has pushed the fight to the states, where a brewing conflict over Medicaid is shaping up as the next battleground.

The Trump administration is expected to rule soon on Kentucky’s push to impose work requirements and other rules on Medicaid enrollees, as other states line up to follow suit. Democrats say that would weaken the program.

This issue could be the next step in transforming a large swatch of the American health-care system, as Congress remains deadlocked between Democrats who back the Affordable Care Act, some of whom say it could be improved, and Republicans who want to uproot it but lack the votes to do so.

If states succeed in attaching tougher requirements to Medicaid, which covers one in five Americans, experts say it could become less of a traditional entitlement program and more of an arrangement where many participants earn the right to benefits only if they take certain actions.

“It is easier to take coverage away in below-the-radar, bureaucratic ways,” said Benjamin Sommers, a physician and health economist at Harvard University. “If you ask people if people on Medicaid should have to work, that’s popular, but if you ask people if they should cut Medicaid, it’s not. (But) the first may lead to the second.”

Republicans argue that Medicaid, which provides benefits to about 75 million Americans, has become far more than a safety net. Its growth, they argue, has fostered dependence by participants and threatened to swallow state budgets.

Democrats defend Medicaid as a vital form of public assistance for low-income and disabled Americans, saying it leads to better health for consumers, lowers costs for hospitals, and is essential for the needy. The proposed waivers, they say, endanger those social benefits.

Curtailing the entitlement could be politically tricky, since Medicaid’s popularity has grown in recent years, and during the 2016 presidential campaign, then-candidate Donald Trump promised not to cut it. During the Republican push to repeal the Affordable Care Act this year, proposed cuts to Medicaid fractured the GOP, becoming a central reason the repeal stalled.

The dispute also could sharpen a divide in health coverage between red and blue states. States with GOP governors and legislatures are among those with the highest percentages of uninsured, in part because they declined to take part in the ACA’s Medicaid expansion. The new Medicaid requirements could create more barriers to coverage.

A key voice within the Trump administration on the waiver requests is likely to be Seema Verma, head of the Centers for Medicare and Medicaid Services. As a consultant in Indiana, Ms. Verma helped impose requirements such as premiums on Medicaid recipients there.

Conservative state leaders hope she will approve similar requirements for them. Democrats argue that some of the more far-reaching proposals aren’t legally permissible.

A CMS spokeswoman said there is no deadline for decisions on the waivers and the process is continuing on as normal despite the recent resignation of Health and Human Services Secretary Tom Price.

Kentucky is likely to be a test case. Under the state’s waiver request, even lower-income beneficiaries would have to pay premiums based on a sliding scale, a requirement not found in most states. Many enrollees who failed to pay would be locked out of coverage for six months unless they took a financial or health literacy course and paid what they owed.

In addition, most adults would have to perform weekly job-related activities, potentially including training or volunteer work.

The proposal “is a plan tailored to meet the unique needs of Kentuckians,” said Doug Hogan, a spokesman for the governor. “It is a consumer-oriented health plan that in many ways mirrors commercial insurance coverage.”

Others say the requirements are impractical for struggling Americans who may be juggling child care, medical costs and other expenses. Health coverage is a right, they say, not a privilege to be earned by following government-imposed requirements.

“It’s a big concern,” said Clare White, a 27-year-old Medicaid beneficiary of Georgetown, Ky., who has been out of work since her job as a nanny ended. “I really like the way it works right now. I don’t need to be patronized or talked down to with these requirements.”

The battle has particular resonance in Kentucky because it is a rare conservative state that embraced the ACA and saw its uninsured rate fall sharply. Along with Arkansas, Kentucky was among the top two states to see the largest drop in its uninsured rate among states that expanded Medicaid. Seventeen states that have Republican governors as of August 2017 have expanded Medicaid, according to the Kaiser Family Foundation.

To ACA backers, that makes Kentucky a welcome success story, but conservatives there bemoan what they see as a jump in government benefits with little accountability.

President Donald Trump confirmed Saturday morning that he called Senate Minority Leader Chuck Schumer to explore whether Democrats “want to do a great HealthCare Bill,” Trump wrote on Twitter Saturday morning. The president made sure it was clear he has no idea what could happen next: “Who knows

Trump made the call in an effort to seek a “path forward on health care,” according to a GOP source who talked to Axios, which was the first to break the story on Friday night. But Schumer quickly put out his own statement making it clear that a repeal of Obamacare was out of the question.

“The president wanted to make another run at repeal and replace and I told the president that's off the table,” Schumer said. “If he wants to work together to improve the existing health care system, we Democrats are open to his suggestions. A good place to start might be the Alexander-Murray negotiations that would stabilize the system and lower costs."

This is, of course, hardly the first time the president tries to team up with Schumer. But everyone quotes a Democratic aide who clearly wants to tone down expectations that there will be bipartisan cooperation on the issue at a time when there is lots of anger about the way the Trump administration is allowing employers to claim a religious or moral objection to the Affordable Care Act’s contraceptive mandate. “Particularly after the birth control decision yesterday, the administration has to stop sabotaging the law before anything real can happen,” the aide said

WASHINGTON — President Trump signed an executive order on Thursday that clears the way for potentially sweeping changes to the country’s health insurance system, including sales of cheaper policies with fewer benefits and protections for consumers than those mandated under the Affordable Care Act.

The president’s plan, an 1,100-word directive to federal agencies, laid the groundwork for an expanding array of health insurance products, mainly less comprehensive plans offered through associations of small employers and greater use of short-term medical coverage.

It was the first time since efforts to repeal the landmark health law collapsed in Congress that Mr. Trump has set forth his vision of how to remake the nation’s health care system using the powers of the executive branch. It immediately touched off a furious debate over whether the move would fatally destabilize the Affordable Care Act marketplaces or add welcome options to consumers complaining of high premiums and not enough choice.

In Congress, the move seemed to intensify the polarization over health care. The Senate majority leader, Mitch McConnell of Kentucky, said the president was offering “more affordable health insurance options” desperately needed by consumers. But the Senate Democratic leader, Chuck Schumer of New York, said Mr. Trump was “using a wrecking ball to single-handedly rip apart our health care system.”

Most of the changes will not occur until federal agencies write and adopt regulations implementing them. The process, which includes a period for public comments, could take months. That means the order will probably not affect insurance coverage next year, but could lead to major changes in 2019.

With these actions,” Mr. Trump said at a White House ceremony, “we are moving toward lower costs and more options in the health care market, and taking crucial steps toward saving the American people from the nightmare of Obamacare.”

“This is going to be something that millions and millions of people will be signing up for,” the president predicted, “and they’re going to be very happy.’’

But many patients, doctors, hospital executives and state insurance regulators were not so happy. They said the changes envisioned by Mr. Trump could raise costs for sick people, increase sales of bare-bones insurance and add uncertainty to wobbly health insurance markets.

“Today’s executive order could leave millions of cancer patients and survivors unable to access meaningful coverage,’’ said Chris Hansen, the president of the lobbying arm of the American Cancer Society.

In a statement from six physician groups, including the American Academy of Family Physicians, the doctors predicted, “Allowing insurers to sell narrow, low-cost health plans likely will cause significant economic harm to women and older, sicker Americans who stand to face higher-cost and fewer insurance options.”

President Donald Trump's recent, aggressive actions on health care will make it harder for people to access care, Maine Republican Sen. Susan Collins warned on Sunday.

"What the President is doing is affecting the ability of vulnerable people to receive health care right now," Collins said on CNN's "State of the Union."

Trump on Thursday signed an executive order that could dismantle some of the rules around the Obamacare marketplaces, and the administration announced later the same day it would end subsidies geared toward helping low-income people afford care.

She said she believed the actions Trump took will hurt American citizens.

"These certainly are very disruptive moves that will result in smaller numbers of people being insured, that will make it more difficult for low-income people to afford their out-of-pocket costs and that will destabilize the insurance markets," Collins said.

Collins denied the subsidies were "a bailout of the insurers," as the White House contended, and said the payments helped people access health care.

"If they can't afford their deductible, then their insurance is pretty much useless," Collins said.

This is, of course, hardly the first time the president tries to team up with Schumer. But everyone quotes a Democratic aide who clearly wants to tone down expectations that there will be bipartisan cooperation on the issue at a time when there is lots of anger about the way the Trump administration is allowing employers to claim a religious or moral objection to the Affordable Care Act’s contraceptive mandate. “Particularly after the birth control decision yesterday, the administration has to stop sabotaging the law before anything real can happen,” the aide said

I hope Trump supporters don't complain when they lose their health insurance and/or their premiums go through the roof. The ACA guarantees will disappear, and many will die.

So the Democrats are going to refuse to work with Trump to fix health care?