The state of Kentucky has become the first to adopt the Trump administration’s new policy of imposing work requirements as a precondition of receiving Medicaid benefits.
Consequently, residents of Kentucky who are on Medicaid and considered healthy enough to work, must now comply with certain requirements to receive the health care provided by the government program.
The Trump administration announced on January 11 that states could impose work requirements on Medicaid recipients. One day later, the Center for Medicare and Medicaid Services approved a waiver for Kentucky adopting that new policy for the next five years. Under the program, which officially starts in July, Medicaid beneficiaries between the ages of 19 and 64 who do not meet exemption requirements must complete at least 80 hours per month of “community engagement,” which includes work, school, job skills training, or community service. If they do not complete the requirements, Medicaid eligibility will be suspended. The program exempts several categories of recipients, including pregnant women, those diagnosed as “medically frail,” primary caregivers, and former foster care youth.
“It will be transformational,” Kentucky Governor Matt Bevin said in an announcement Friday. “Transformational in all the right ways, in good ways, in powerful ways.”
More than 2 million people are on Medicaid in Kentucky, according to the Kaiser Family Foundation, which is nearly one quarter of the state’s population. Kentucky was among the 33 states to adopt the Medicaid expansion program that is a cornerstone of the Affordable Care Act enacted under the Obama administration, but Bevin has been seeking to implement these changes since he was elected in 2015.
Bevin also defended the program from criticism that it was essentially punishing lower income people, and insisted that the program will only impact those who are physically able to work. The recipients of the program who are unable to comply with the new regulations, he said, will remain unaffected.
“This idea that somehow we are punishing people, that this will be a detriment to people I think is a huge huge misunderstanding of what people need,” he said, noting that he himself came from a low-income family. “There is dignity associated with owning the value of something you receive.”
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Everybody says they want bipartisan solutions to complex problems, but what happens when a bipartisan solution actually shows up? In Donald Trump’s Washington, the answer is that whether it actually comes to fruition depends on the shifting whims of a president who doesn’t understand the issue and can’t even figure out what he wants to do.
President Trump is facing a dilemma: Does he want to destroy the American health-care system or not? At this point, all evidence suggests that he genuinely can’t decide what the answer to that question is.
As you know, Sens. Patty Murray (D-Wash.) and Lamar Alexander (R-Tenn.) have announced that they reached an agreement on a short-term plan to stabilize the health-care exchanges. It would continue the cost-sharing reduction (CSR) payments in the Affordable Care Act that Trump recently announced he’d be halting; give states greater flexibility to receive waivers of certain requirements in the ACA; restore funding for outreach to encourage people to sign up for coverage, which the administration has slashed; and allow more people to get high-deductible “catastrophic” coverage.
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In other words, the compromise offers something for Democrats and something for Republicans. By no means would it solve every issue the law has, but it’s meant to provide some short-term certainty, which should slow the dramatic premium increases insurers have requested since the Trump administration began its campaign of sabotage against the law.
When the Alexander-Murray agreement was announced yesterday, Trump at first seemed supportive. “It is a short-term solution, so that we don’t have this very dangerous little period — including dangerous periods for insurance companies,” he said at a press conference. “For a period of one year, two years, we will have a very good solution.” But then this morning, he tweeted, “I am supportive of Lamar as a person & also of the process, but I can never support bailing out ins co’s who have made a fortune w/ O’Care.”
What gives? When you try to interpret the president’s shifting positions — and figure out how this is all going to end — there are a few things you have to keep in mind. First, it’s wise to assume that he has no idea how any provision of this agreement or the ACA itself actually works, and that will not change. For instance, he seems to have convinced himself that cost-sharing reductions are like an extra bonus given to insurance companies that they’ll just use to pad their profits. “That money is going to insurance companies to lift up their stock price,” he has said, when in fact the money is basically passed through the insurers to provide lower co-payments and deductibles for people with low incomes. He hasn’t bothered to learn what the law does, and he certainly isn’t going to quickly get up to speed on new proposals to provide technical fixes.
Second, you have to remember that Trump has no ideological principles on health care that can provide us a guide to what he might do. At various times he has embraced viciously cruel Republican plans that would cut off coverage for tens of millions, and said he wants the government to provide “insurance for everybody.” He simply has no consistent beliefs on this subject (and, of course, on many others).
Third, he is pushed in different directions by competing impulses, any one of which may dominate at a particular moment. It has become clear that there may be no desire that governs his actions more than his need to destroy and discredit everything Barack Obama did. We can debate why this is; my view is that Trump, who is obviously a deeply insecure man, looks at Obama and sees someone who is his superior in almost every way — smarter, more competent, more admired and respected — and is enraged by the inevitable comparisons. But the fact that Trump is driven to undo anything with Obama’s name on it is undeniable.
That goes a long way toward explaining why Trump is so eager to destroy the individual insurance market, at the cost of enormous anxiety and suffering among the public, when his advisers have surely explained to him that he will be held responsible for whatever happens to American health care on his watch. No matter how much it costs him politically, he wants to be able to say that Obamacare is dead, he killed it, and it was a terrible thing in the first place.
However, at the same time Trump is desperate to show that he can make a deal. The failure of the GOP effort to repeal the ACA plainly weighs on him. Despite his belief that he is the greatest dealmaker in human history, you may have noticed that he has negotiated precisely zero deals of any magnitude since becoming president. The Republican Congress has passed no major legislation this year. Trump’s increasingly desperate and comical insistence that he is piling up an awe-inspiring record of accomplishment — “in nine months, we have done more, they say, than any president in history,” he said today — only highlights his eagerness to have something he can say he actually got done.
Which raises the question of what he would do if the Alexander-Murray agreement actually passed both houses of Congress and found its way to his desk. My guess is that if he were actually presented with the choice he’d sign it, if for no other reason than that issuing a veto would be taking a firm stand. But before we get there, he’s going to keep undermining it with his public comments. That will only add fuel to the belief of ultra-right Republicans in the House that any bill that doesn’t set Barack Obama’s legacy aflame is a compromise with their beliefs and therefore unacceptable.
All of which suggests that though the Alexander-Murray agreement sounds like a perfectly reasonable thing to do and something Democrats and Republicans ought to be able to agree on, it’s more likely than not that it will fail. That won’t be entirely Trump’s fault, but he certainly won’t be helping.
At the end of six months in office, Donald Trump doesn’t have a single legislative achievement to crow about. The failure to repeal ‘Obamacare’ is the biggest. Another setback for Trump is Congress’ move to impose new sanctions on Russia. Added to this is the investigation into his and his team’s involvement with Russia during the 2016 election
US President Donald Trump’s poll ratings are lower than ever – and the lowest of any president at such an early point in an administration. Members of his own Republican Party are distancing themselves from him(AFP)
Even with a new minder trying to bring some order to the White House, United States President Donald Trump remains in a heap of trouble. The recent installation of retired general John Kelly, formerly Trump’s secretary for homeland security, as chief of staff, replacing the hapless Reince Priebus, has reduced some of the internal chaos and induced a bit more discipline in Trump’s behaviour. But all this could change any day, or at any moment.
Kelly has put a stop to aides sauntering into the Oval Office whenever they felt like it –Trump tends to echo the last person he’s spoken with – and has demanded that papers and memos for the president be submitted to him first. For the time being, at least, the president’s tweeting has been reduced in number and nuttiness.
Keen Trump observers expect that he’ll soon begin to chafe under the discipline Kelly has encouraged. Understanding Trump’s enormous ego, Kelly is said to encourage gently rather than instruct. Kelly also has the advantage of Trump’s high regard for generals.
But Trump could well become incensed by news stories praising Kelly for bringing order to the White House. (Counsellor Steve Bannon never fully recovered in the president’s esteem after he was on the cover of Time magazine soon after the inauguration.)
Meanwhile, Trump’s poll ratings are lower than ever – and the lowest of any president at such an early point in an administration. Members of his own Republican Party are distancing themselves from him.
The recent failure of the Republican-dominated Congress to repeal Barack Obama’s signature achievement, the Affordable Care Act, which made healthcare available for millions of people who previously couldn’t afford it, was a humiliating defeat for Trump. Just enough Republican senators (three, but more were in reserve if needed) voted to reject the last of several efforts to fulfil the party’s vow to replace ‘Obamacare’.
That nickname for the ACA, coined by the Republicans when the law was enacted in early 2010, was intended to be derogatory, and their opposition to the program seemed to be vindicated in that year’s midterm elections, when they swept both houses of congress. But the Republicans didn’t reckon on two things: that as people gained access to health insurance (some 20 million by this year), it became popular – as did Obama, who ended his second term as one of America’s most liked presidents.
Over Obama’s tenure, Republicans came to realise that it was no longer sufficient simply to call for a repeal of ‘Obamacare’, and their rhetoric shifted to the need to “repeal and replace”. They held more than 50 roll-call votes saying that they’d do just that, knowing that it didn’t really matter because Obama would veto any serious repeal. The roll calls were actually fundraisers: Appeals to the unsuspecting Republican base to send money to keep up the fight against the supposedly hated programme.
But when the 2016 election put a Republican in the White House, the party’s congressional leaders had nowhere to hide. The Republicans were now in full control of the government – and they hadn’t a clue about what should replace Obamacare.
At the end of six months in office, Trump doesn’t have a single legislative achievement to crow about (though he has claimed the Senate’s approval of Neil Gorsuch as a new Supreme Court justice as a victory). Significantly, Senate Republican leaders ignored Trump’s demand that they take up repeal and replace of Obamacare again, before they consider any other major issue.
While the healthcare bill was commanding most of the attention on Capitol Hill, another piece of legislation was moving along in the Congress, representing another setback for Trump. Troubled by the president’s apparent soft spot for (or perhaps fear of) Vladimir Putin, overwhelming bipartisan majorities in both chambers passed a bill to impose more sanctions on Russia and – most unusually – to prevent the president from lifting any such penalties. And, because the bill passed with enough votes to override a presidential veto, Trump had little choice but to sign it, which he did in private, without the customary presence of a bill’s sponsors and the press.
Meanwhile, the investigation into Trump and his campaign’s relations with Russia in connection with its meddling in Trump’s favour in the 2016 election has continued out of the public’s sight. That investigation has broadened to include Trump’s son-in-law Jared Kushner and his son Donald Jr.
This spring, Trump let it be known that he wanted the special counsel running that investigation, Robert Mueller, a former FBI director who is highly respected by both parties, to be fired. He’d already fired FBI director James Comey, but by law, he couldn’t fire Mueller himself, so he tried to bully Attorney General Jeff Sessions, who had (appropriately) recused himself from the investigation, into resigning. That way, Trump could appoint a replacement who would fire Mueller.
But Sessions, the first Republican senator to endorse Trump, was enjoying rolling back numerous Obama-era protections in areas like civil rights, and refused to resign. Several of Sessions’ former Senate colleagues also demanded that Trump back off. Though Kelly called Sessions to tell him that his job was safe, Republican senators, concerned that Trump might remove him during the August recess, established a procedure that would prevent Trump from appointing an interim attorney-general to fire Mueller, and warned that such a move would provoke a constitutional crisis.
Then, as Congress prepared to leave for the August recess, it was learned that Mueller – who had hired highly regarded prosecutors specialising in international financial transactions, despite Trump’s warnings not to investigate his finances – had impaneled a grand jury in Washington. The noose tightens.
With the future of the Senate health care bill hanging by a thread, President Donald Trump pressed Republican senators to fulfill their party’s seven-year promise to get rid of Obamacare.
Flanked by families Trump said had suffered under the Affordable Care Act, he said, “So far, Senate Republicans have not done their job in ending the Obamacare nightmare.”
Many senators remain in the dark as to what piece of legislation they will be voting on. Trump spoke only of passing a bill to repeal and replace the sweeping health care law without endorsing a specific bill.
Here are some of his statements and the fact-checks we’ve examined in the past.
“Obamacare has broken our health care system. It’s broken. It’s collapsing.”
While Trump has often said that Obamacare is collapsing, the first part of that statement goes further to say that the law has broken the entire health care system. This is not accurate.
The reality is that much of the care people receive continues as before, and by some measures, the system is on better footing than before. Hospitals, for example, spent about $6 billion less between 2013 and 2014 on care for which they received no payment. So-called uncompensated care fell mainly in states that expanded the Medicaid program to all poor adults, according to a study by the Kaiser Family Foundation. That bottom line improvement made hospitals more financially stable.
As for the individual insurance market, the part of Obamacare that Trump has said before is in a death spiral, we have rated statements like that False.
The CBO said even though premiums have been rising, most of the people who buy through the government-run insurance exchanges are protected by the subsidies that are built into the law.
“The subsidies to purchase coverage, combined with the effects of the individual mandate, which requires most individuals to obtain insurance or pay a penalty, are anticipated to cause sufficient demand for insurance by enough people, including people with low health care expenditures, for the market to be stable in most areas.”
That said, as recently as July 12, the Kaiser Family Foundation found that 38 counties in the country are at risk of not having a single health insurance provider in 2018.
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President of the United States
“Obamacare has broken our health care system. It’s broken. It’s collapsing.”
In a speech at the White House – Monday, July 24, 2017
“They (senators) can now keep their promise to the American people to provide emergency relief to those in desperate need of help, and to improve health care for all Americans.”
Trump makes it sounds like aid would be readily available to struggling health care consumers. The “emergency relief” in the Senate bill would actually go to insurance companies and state governments. While some of the money would help individuals, most of the benefits would be indirect and might take time to come together.
The Senate bill contains $182 billion designed to keep premiums down and encourage insurance companies to continue to sell policies in more local markets. The money comes in two pots.
The first is $50 billion over two years that insurance companies could request from the federal government to offset losses. In theory, this protection would reduce the risk to carriers and lead to lower insurance premiums.
Another $132 billion would be spread out over a number of years and would go to the states. States could use this money to pay the premiums for people in high risk pools. They could also provide additional premium subsidies and pay hospitals, doctors and other health care providers.
The precise impact of this is difficult to predict. Premium subsidies would tend to push premiums down. At the same time, the Senate bill gives insurers more flexibility to charge more to older policy holders. That, coupled with higher deductibles and other out-of-pocket expenses, could produce uneven effects.
According to the Kaiser Family Foundation, “older, lower-income people generally would see the largest increases; younger and more affluent people would see decreases in many locations.”
“The Senate is very close to the votes it needs to pass a replacement. The problem is we have zero help from the Democrats. They’re obstructionists.”
Trump is correct that zero Democrats support Republican efforts to repeal and replace the Affordable Care Act. But blaming Democrats for Senate Republicans’ failure to pass legislation doesn’t tell the whole story.
Because the GOP holds 52 Senate seats to Democrats’ 48, Democrats would be powerless to stop a united GOP caucus from passing legislation to dismantle Obamacare. In fact, Republicans could afford to lose two members and still pass the bill, with Vice President Mike Pence casting the tie-breaking vote.
The truth is Senate Republicans have been unable to agree on a replacement package that reconciles divisions between its more moderate and conservative members.
Defections by four GOP senators effectively killed the repeal-and-replace plan on July 17. The following day, a more modest repeal bill was doomed after three Senate Republicans came out in opposition.
Later in his speech, Trump appeared to acknowledge the difficulty of reaching an agreement given Senate Republicans’ slim margin of error.
“The Democrats aren’t giving us one vote, so we need virtually every single vote from the Republicans,” he said. “Not easy to do.”
The bill provides “more flexibility for states to administer Medicaid to better serve their poorest citizens.”
The Senate bill would fundamentally change Medicaid financing. Instead of the open-ended commitment it is today, the program would be put on a budget. States could choose to receive federal dollars based on a per-person formula, or they could take the money as a block grant. Either way, many federal rules would disappear, and states would gain the flexibility to spend Medicaid dollars as they see fit, as Trump said.
On the other hand, Washington would be much less generous with states than it is today. Medicaid spending would continue to rise, but at a much slower rate. The CBO estimated that by 2026, states would be getting 26 percent less than they would if the law remained the same. The cumulative difference over the next 10 years would be $756 billion.
This proposal has driven a wedge in the Republican ranks, dividing senators from states that want to preserve as much of the Medicaid funding as possible — essentially in states that expanded Medicaid — from those who feel the current system puts them at a disadvantage or simply spends too much.
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that Republican leaders released on Thursday morning seemingly has something for everyone—but perhaps not enough for anyone.
Seeking to quell a revolt from more than one-fifth of his conference, Majority Leader Mitch McConnell agreed to forego two significant tax cuts for the wealthy and instead pour hundreds of billions of dollars back into the proposal he released two weeks ago. There’s now $45 billion to combat opioid addiction and even more funding to help mitigate higher insurance costs for low-income people and to stabilize the individual markets. An additional $70 billion would go to states to help drive down premiums, on top of $112 billion that was in the original proposal. McConnell’s target was senators toward the center of the Republican ranks, who represented the largest bloc of opposition to his first legislative draft.To woo conservative critics, the majority leader added a provision based on a proposed amendment from Senators Ted Cruz of Texas and Mike Lee of Utah—backed by pressure from a number of activist groups—that would allow insurance companies to sell stripped-down, inexpensive plans that don’t conform to Obamacare’s standards as long as they offer at least one policy that does. Well, sort of. McConnell’s draft includes the Cruz-Lee idea in brackets, an indication of its polarizing and therefore precarious status within the GOP health-care debate.
McConnell needs to pick up support from both ends of the ideological spectrum. He can afford only two Republican defections, and at least 10 of his members had come out against the first version of the Better Care Reconciliation Act before McConnell abandoned plans to bring it up for a vote last month. Two of those critics, Senator Susan Collins of Maine in the center and Senator Rand Paul of Kentucky on the right, appear to have hardened in their opposition this week. Collins said it would take “a complete overhaul” to win her support, and Paul has gone on a media tour to rail against the revised proposal, saying that based on what he had heard, it was even worse than the original because it repealed less of Obamacare and included a bigger “bailout” for insurers.
Within hours after the revised draft’s release, both Paul and Collins reiterated their opposition to it an d said they would vote against even bringing it up for debate. As on the final vote, McConnell needs at least 50 Republicans to sign off on the procedural motion, and with Paul and Collins apparently out, he needs every other member of his conference to agree.
In a speech on the Senate floor after unveiling the bill to Republicans, McConnell pleaded with his colleagues to allow it at least to come up for debate. “I hope every senator will vote to open debate. Because that’s how you change the status quo,” he said. “This is our opportunity to really make a difference on health care. This is our chance to bring about changes we’ve been talking about since Obamacare was forced on the American people. It’s our time to finally build the bridge away from Obamacare’s failures and deliver relief to those who need it.”While McConnell picked quick support from several party loyalists, most of the holdouts on the original draft remained undecided. Senators Rob Portman of Ohio and Shelley Moore Capito of West Virginia said they would review the bill, as did Senator Dean Heller of Nevada, a sharp critic initially who is under intense pressure in the run-up to a reelection campaign next year. In an ominous sign for McConnell, however, Capito said in a statement she still had “serious concerns” about the proposal.
McConnell all but ignored complaints from moderates to soften the bill’s deepest and most contentious cuts—a $772 billion reduction in Medicaid spending over a decade, with hundreds of billions in additional cuts in the 10 years after that. The cuts, which include a four-year phase-out of Obamacare’s Medicaid expansion and a change in the program’s growth rate, would not begin until 2020. According to the Washington Post, McConnell told moderates to support the bill with those cuts included because they would never go into effect.
Though rather cynical, it’s an assumption held by some in Washington-based on the likelihood that Democrats will win control of the House in 2018 or the presidency in 2020 and work with Republicans to put off the Medicaid cuts.While the new bill maintains most of the Medicaid cuts, it changes the formula under which hospitals would be reimbursed for treating patients that can’t pay their bill. And it would allow states some wiggle room if a public health emergency was declared or to seek a waiver to access more funds to cover the elderly and disabled, according to a summary posted by the Senate Budget Committee.
Yet like the entire bill itself, McConnell’s Medicaid bet is a risky one. Senators like Collins, Lisa Murkowski of Alaska, Heller, Portman, and Capito have strongly opposed the cuts to Medicaid and were already frustrated with the secretive, top-down process McConnell has led on the health-care bill. And conservative activists and senators have pointed to the Medicaid changes as one of the few things they like about a proposal that does not truly fulfill their promise to repeal Obamacare. They had already stomached the Senate’s longer lead-time in ending the ACA’s Medicaid expansion, but will they recoil at McConnell’s reported admission that the reforms might not endure at all?
In another blow to Collins and Murkowski, McConnell also retains provisions blocking federal funds from going to Planned Parenthood and banning the use of subsidies to purchase plans that cover abortion. Both senators had criticized those aspects of the original bill, and if both Collins and Paul vote against the legislation as they’ve indicated, Murkowski’s opposition on those grounds could sink it entirely.
Cruz has demanded the inclusion of his Consumer Freedom Choice Amendment in the underlying Senate bill as the price for his support. But the version that McConnell included was different, Lee tweeted shortly before Republicans were scheduled to see the revised bill for the first time.
While Lee was undecided, Cruz told reporters that he would support the bill as long as his amendment stayed in and no other changes were made. His position appeared to mimic the new stance of conservative activist groups, who have conceded that Republicans can’t fully repeal the Affordable Care Act but in recent days made the adoption of Cruz’s amendment striking at its core regulations their final demand. Even Grover Norquist, the anti-tax activist who has prioritized the repeal of Obamacare’s tax increases, issued a statement signaling he was okay with McConnell’s decision to keep some of them now as long as the leadership committed to getting rid of them in subsequent tax-reform legislation. Norquist told me in an interview last month that keeping the taxes on the wealthy even temporarily was “a bad idea.”
Illustrating McConnell’s challenge in navigating the bill to passage, the changes that Cruz and Lee are demanding could solidify opposition among moderates or lose even more votes among Republicans leery of doing anything that threatens protections for people with preexisting conditions. The health-care industry is aligned against the proposal, which would essentially create separate insurance markets for sick and healthy people. Even the insurance industry’s top lobbying group, America’s Health Insurance Plans, came out in public opposition to the amendment after staying quiet through much of the Senate debate. Whether the Cruz amendment stays in the bill is in doubt. A senior GOP policy staffer said Thursday the provision was put in brackets in the bill text because “the policy is continuing to be worked on as members react to it.” Republicans have asked the Congressional Budget Office to score versions of the bill with and without the Cruz policy, but it’s unclear whether the report released next week will fully assess the amendment.
The next big test for McConnell will come early next week, when the CBO releases its analysis. The original bill fared little better with the CBO than the legislation House Republicans passed in May; the budget office found that the Senate bill would result in 22 million fewer people having health insurance after a decade. McConnell is hoping that the infusion of money into the subsidy and stabilization programs will improve that number and boost support for the bill. But if three or Republicans vote against a procedural motion to bring the proposal to the floor next week, it won’t even see a formal debate.In an indication of how dicey the revised bill’s prospects were, two Republican senators, Lindsey Graham of South Carolina and Bill Cassidy of Louisiana, chose the day of its release to unveil their own, competing idea for a partial replacement of Obamacare. Appearing on CNN before a crucial GOP meeting, they proposed a plan that would do away with Obamacare’s individual and employer mandates but keep most of its tax increases. But instead of funding a federal subsidy program, that revenue would be sent to the states so that they could craft their own health-care plans as they saw fit.
“If you like Obamacare and you want to repair it, you can,” Graham said on CNN. “If you want to replace it, you can.”
The idea is in line with an earlier proposal from Cassidy and Collins that would have allowed states to choose whether they kept Obamacare or not. That plan went nowhere, but with Republicans nearing a stalemate on health care, the senators are betting that their colleagues will give it another look.
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Americans are you sick and tired of the D.C. politicians playing with your healthcare and with your ability to pay for it? Obamacare, Trump-care, repeal and replace, repeal and don’t replace, this amendment and that amendment, are you sick of the political noise and of the politicians not giving a damn about you or your family? Personally I am sick of both political parties who only cater to the Lobbyist and not the voters. This latest GOP Healthcare plan showed once again that the Republican so-called Leadership only cares about the Lobbyist as they released copies of the Bill to Lobbyist before even releasing it to other ‘rank and file’ Republican Senators. For 7 years Republican Lawmakers whined, complained, threatened and promised to repeal and replace ‘Obamacare’ right away as soon as they were in a position to do so. Yet after all of that time they didn’t even have the beginning of any plan.
Here is my plan, yet not just my plan as I have seen a few other people voice this same opinion in writing and verbally. It is a simple plan and it is the most ‘Constitutional’ plan that I believe exist. If indeed if these bought and paid for politicians believe in the Constitution and the Scriptures about all people being created equal and that all people should be treated as equals then there is only one Healthcare program that should be for all people. The concept is simple and it should be legal as it is and has been in place for some folks for decades now. I will quit talking and just spit it out now.—I do not know anything about the plan that covers all of the Senators and Congress men and women and the President but what ever that plan is—that should be the plan that all of the American people have with no exceptions. After all, if it is good enough for ‘our public servants’ then it is good enough for their supposed bosses, ‘We The People’ then it is good enough for the American people also, isn’t it?
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WASHINGTON — The 142-page Senate health care bill released on Thursday is easy to summarize: It cuts health care spending for low-income and middle-income Americans and uses the savings to finance large tax cuts for the wealthy and the medical industry.
How it accomplishes this is simple as well: It makes large cuts to Medicaid and to subsidies for private insurance, meaning large chunks of money that the government would have spent on helping Americans afford coverage, pay for long-term care and reduce their out-of-pocket costs would instead be paid either by states or by the customers themselves.
In this regard, the bill, which is called the Better Care Reconciliation Act, is broadly similar to the American Health Care Act that passed the House in May. There are some significant differences within that framework, however, especially when it comes to private insurance subsidies.
Let’s go through the main planks of the Senate plan:
Medicaid covers about 70 million Americans, including low-income residents, seniors in nursing homes (over 60 percent of whom are on Medicaid) and people with disabilities.
The Senate bill would restructure the program, cap its spending and reduce its funding significantly over time.
Protester Shares Her Reasons For Opposing Health Care Bill0:57
First, the Senate GOP bill would eliminate a major expansion of Medicaid under Obamacare.
The Affordable Care Act gave states federal funding to expand Medicaid coverage to people whose incomes were between 100 percent and 138 percent of the federal poverty line (the current cap is about $34,000 for a family of four). The Supreme Court later made the funding optional, but 30 states and the District of Columbia accepted it. The Senate bill would gradually end this expansion between 2020 and 2024.
But it would go a lot further than repealing Obamacare’s changes. It would also cap the amount of funding states can get on a per-recipient basis rather than continue the current system, in which states decide how much to spend and then have the federal government match their contribution.
Starting in 2025, the plan would then grow those per-recipient caps at a rate that’s unlikely to keep pace with increasing medical costs. A similar change in the House bill was projected to reduce Medicaid spending by $839 billion over a decade and cover 14 million fewer people. The Senate bill kicks in later, but its cuts would be even deeper than the House plan.
To make up the difference, states would either have to raise taxes, cut programs elsewhere or reduce benefits and coverage for recipients. That prospect has governors, including some Republicans like Ohio Gov. John Kasich, nervous that the reduced funding will hamper their ability to respond to health crises like the current opioid epidemic. The bill provides an extra $2 billion next year for substance-abuse treatment, a small number compared to its looming cuts.
But the Medicaid cuts also have small-government conservatives nervous. Congress has a history of passing cuts to services or tax increases and then delaying them down the line. The more time before they kick in, the greater the chance that government control might change hands or public opposition could prompt a reversal.
Private insurance subsidies
When it comes to Obamacare’s subsidies to buy private insurance, the Senate bill keeps the same basic structure, but provides less money for fewer people to purchase insurance that is less generous. These changes would also raise premiums for older people.
Under the current system, people who don’t get health insurance through work or a government program can qualify for help buying a private plan on Obamacare’s exchanges. The maximum amount you’re expected to contribute is capped based on your income.
There are limits, though. If your income is higher than 400 percent of the federal poverty line — about $98,000 for a family of four — you don’t get those subsidies. This is one of the biggest gripes about Obamacare: While most people qualify for aid, those who miss the cutoff have to pay full price, which can be difficult to afford.
The Senate bill would expand this complaint to a wider group. It would cut the subsidies off at 350 percent of the federal poverty line instead, about $86,000 for the same family. On the other hand, it would also cover some lower-income people who currently fall in the “Medicaid gap” in states that didn’t take the federal expansion.
Those who qualify for subsidies could also pay higher premiums. Under current law, no Obamacare recipients are expected to contribute more than 9.5 percent of their income in premiums. But the Senate bill changes this and make the caps more generous for younger customers and less generous for older customers. A 60-year-old making $42,000 would now have to contribute as much as 16 percent of their income to premiums.
In addition, the subsidies would be pegged to less comprehensive insurance. Under the current law, they’re calculated based on a “silver plan” that covers an average of around 70 percent of medical costs. The new bill would peg them to plans that cover only 58 percent of costs. That means higher deductibles, which have also been a major complaint among Obamacare users.
Out-of-pocket expenses would actually go up even higher for many Americans. Obamacare provided “cost-sharing reduction” payments to insurers, which they used to lower expenses for customers making up to 250 percent of the federal poverty line (about $61,500 for a family of four). For those at 150 percent of the line, these payments reduced the average deductible from $3,609 to just $255, according to the Kaiser Family Foundation. But the Senate bill ends those subsidies starting in 2019.
This is still a big difference from the House bill, which would have offered only fixed tax credits. Those credits would have likely fallen far short for many people, especially older, lower-income customers in places with high health care costs, which are often rural areas. Now the subsidies will scale up to meet the costs in their area, even if they fall short of current levels.
In addition to the subsidies, the bill provides significant funding to help stabilize insurance markets in the short-term (which have been jittery, partly due to the health care debate) and a $62 billion fund over eight years to help states potentially cover more expensive patients. But the funding is temporary, making the future uncertain.
The Senate bill does not let insurers deny people coverage based on a pre-existing condition or charge them more based on their health, which keeps two core pieces of Obamacare in place.
However, this doesn’t mean those with pre-existing conditions won’t potentially be affected. The bill does give states flexibility to waive Obamacare’s “essential health benefits,” a list of 10 broad categories of coverage every insurance plan needs.
Republicans argue states should be able to eliminate those requirements in order to lower overall premiums and provide more flexibility to insurers and customers. In the pre-Obamacare era, insurance companies often didn’t cover items like maternity care or mental health treatment, two items that are included in “essential health benefits.”
Some health experts fear that insurers will try to shepherd healthier patients into cheaper plans that cover fewer items, leaving patients with pre-existing conditions struggling to find an affordable option that covers their treatment. So even though insurers will not be able to discriminate based on pre-existing conditions, the effect could be to make their care less affordable.
Importantly, items that aren’t considered essential health benefits could be subjected to lifetime or annual limits by insurers, a practice that Obamacare eliminated.
The individual mandate
There would be no individual mandate requiring that people buy insurance, which penalized people who went without coverage.
The goal was to encourage younger and healthier people to enter the market so insurers weren’t left on the hook for only more expensive patients who were more likely to seek coverage. It didn’t work as well as intended, however, and insurers complained that the penalties were too weak and left them with a sicker crop of patients who required them to raise premiums to cover.
Schumer, Pelosi Denounce Senate GOP’s ‘Heartless’ Health Care Bill 1:19
This bill eliminates the penalties entirely, though, and instead counts on healthier people deciding coverage is affordable enough for them to get covered. That could be a problem if they conclude that the new insurance, which could have higher deductibles, is not worth the trouble.
“I just don’t see why people would sign up,” Joe Antos, a fellow at the American Enterprise Institute, told NBC News.
If they don’t come off the sidelines, or if they drop their existing coverage, premiums could rise for everyone as markets become dominated by sicker customers. The Society of Actuaries indicated in a statement on Thursday they would be watching this issue closely.
Unless you were paying a penalty for not carrying insurance, it’s unlikely you’ll notice any change in your taxes as a result of the Senate bill.
For rich people, though, the Senate bill is a nice income boost. It eliminates a surtax on income and investment gains for individuals making over $200,000 a year and married couples making over $250,000 a year. The bill also cuts taxes on health companies like medical device manufacturers and prescription drug companies.
Does it have ‘heart?’
President Donald Trump said recently that the Senate bill should be “something with heart.”
“Heart” is a subjective idea, but Trump laid out very specific standards as a candidate and as president. By those standards, the bill falls short.
Trump explicitly pledged he would make no cuts to Medicaid. Instead, the bill will cut Medicaid by hundreds of billions of dollars. He promised “insurance for everybody” backed by federal spending: Instead the bill will likely cover millions fewer people than current law. He repeatedly promised lower deductibles: Instead a core feature of the bill pushes customers towards higher deductible plans. He argued his dedication to providing more generous health care distinguished him from conservative Republicans who sought smaller government.
“This bottom line is that this bill will result in a very significant reduction in insurance coverage, as well as large increases in premium and out-of-pocket costs for those who manage to retain coverage,” Matthew Fiedler, a fellow at the Brookings Institute, told NBC News.
Should the bill become law, these will be unambiguous broken promises.
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WASHINGTON — Senate Republicans, who have promised a repeal of the Affordable Care Act for seven years, took a major step on Thursday toward that goal, unveiling a bill to cut Medicaid deeply and end the health law’s mandate that most Americans have health insurance.
The 142-page bill would create a new system of federal tax credits to help people buy health insurance, while offering states the ability to drop many of the benefits required by the Affordable Care Act, like maternity care, emergency services and mental health treatment.
The Senate bill — once promised as a top-to-bottom revamp of the health bill passed by the House last month — instead maintains its structure, with modest adjustments. The Senate version is, in some respects, more moderate than the House bill, offering more financial assistance to some lower-income people to help them defray the rapidly rising cost of private health insurance.
But the Senate measure, like the House bill, would phase out the extra money that the federal government has provided to states as an incentive to expand eligibility for Medicaid. And like the House measure, it would put the entire Medicaid program on a budget, ending the open-ended entitlement that now exists.
It would also repeal virtually all the tax increases imposed by the Affordable Care Act to pay for itself, in effect handing a broad tax cut to the affluent, paid for by billions of dollars sliced from Medicaid, a health care program that serves one in five Americans, not only the poor but almost two-thirds of those in nursing homes. The bill, drafted in secret, is likely to come to the Senate floor next week, and could come to a vote after 20 hours of debate.
If it passes, President Trump and the Republican Congress would be on the edge of a major overhaul of the American health care system — one–sixth of the nation’s economy.
The premise of the bill, repeated almost daily in some form or other by its chief author, the Senate majority leader, Mitch McConnell of Kentucky, is that “Obamacare is collapsing around us, and the American people are desperately searching for relief.”
Mr. Trump shares that view, and the Senate bill, if adopted, would move the president a great distance closer to being able to boast about final passage of a marquee piece of legislation, a feat he has so far been unable to accomplish.
Democrats and some insurers blame the Republicans and Mr. Trump for sabotaging the law, in part by threatening to withhold subsidies used to help pay for deductibles and co-payments for millions of poor people covered by the law.
In the Senate, Democrats are determined to defend a law that has provided coverage to 20 million people and is a pillar of former President Barack Obama’s legacy. The debate over the repeal bill is shaping up as a titanic political clash, which could have major implications for both parties, affecting their electoral prospects for years to come.
Mr. McConnell faces a great challenge in amassing the votes to win Senate approval of the bill, which Republicans are trying to pass using special budget rules that will allow them to avoid a Democratic filibuster. But with only 52 seats, Mr. McConnell can afford to lose only two Republicans, with Vice President Mike Pence breaking the tie. He may have already lost one — Senator Rand Paul, Republican of Kentucky, has indicated repeatedly that the bill is too liberal for him.
Democrats are unified in opposing the repeal efforts, and they have already assailed Republicans for the work they have done so far, criticizing them for putting the bill together without a single public hearing or bill-drafting session.
In the short term, the possible electoral consequences are more muted in the Senate than in the House, as only two of the Senate Republicans who face re-election next year, Dean Heller of Nevada and Jeff Flake of Arizona, are seen as vulnerable.
But Republican leaders still must contend with internal divisions that will be difficult to overcome. Numerous Republican senators from states that expanded Medicaid are concerned about how a rollback of the program could affect their constituents, and they face pressure from governors back home.
Some senators have concerns based on other issues specific to their states, including the opioid epidemic that has battered states like West Virginia and Ohio. And some of the Senate’s most conservative members could resist a bill that they view as not going far enough in dismantling the Affordable Care Act.
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Senators will not have long to sort out their differences. Mr. McConnell wants to hold a vote before lawmakers return home for the Fourth of July recess. If the repeal bill is still looming over the Senate, Republicans are certain to face intense pressure from constituents who wish to see the Affordable Care Act remain in place.
The assessment being made by senators will be shaped in part by an analysis of the bill to be released by the Congressional Budget Office, the official scorekeeper on Capitol Hill.
President Donald Trump on Tuesday criticized the House-passed health care bill, calling it “mean” in a meeting with Republican senators and urging them to develop a “more generous” version. But just over a month ago, the president repeatedly praised the GOP-sponsored legislation, describing it as a “great plan” after a vote confirmed the bill’s approval in the House.
Trump said the bill would make insurance prices go down
“And I will say this, that as far as I’m concerned, your premiums, they’re going to start to come down,” Trump said during the beginning of his remarks, before later adding: “And I think, most importantly, yes, premiums will be coming down. Yes, deductibles will be coming down. But very importantly, it’s a great plan. And ultimately, that’s what it’s all about.”
A forecast from the Congressional Budget Office, an independent, nonpartisan agency, said that premiums will actually increase over the next few years should the bill pass in its current form, and long-term effects will ultimately fall to individual states.
He said it was good because it would repeal and replace Obamacare
“Right now, the insurance companies are fleeing. It’s been a catastrophe. And this is a great plan,” Trump said. “I actually think it will get even better. And this is, make no mistake, this is a repeal and replace of Obamacare. Make no mistake about it. Make no mistake.”
He said it was great because it was done quickly
“And this really helps it. A lot of people said, how come you kept pushing healthcare, knowing how tough it is? Don’t forget, Obamacare took 17 months. Hillary Clinton tried so hard — really valiantly, in all fairness, to get healthcare through. Didn’t happen,” Trump remarked. “We’ve really been doing this for eight weeks, if you think about it. And this is a real plan. This is a great plan. And we had no support from the other party.”
He said it had “great features”
“But we want to brag about the plan, because this plan really — uh oh,” Trump began before he was cut off by a laughing audience. “Well, we may. But we’re just going to talk a little bit about the plan, how good it is, some of the great features.”
And overall, he said it was good because of the “talent” that helped develop it
“So what we have is something very, very incredibly well-crafted. Tell you what, there is a lot of talent standing behind me. An unbelievable amount of talent, that I can tell you. I mean it,” Trump gushed.
“But we have an amazing group of people standing behind me,” the president added. “They worked so hard and they worked so long. And when I said, let’s do this, let’s go out, just short little shots for each one of us and let’s say how good this plan is — we don’t have to talk about this unbelievable — wasn’t it unbelievable? So we don’t have to say it again. But it’s going to be an unbelievable victory, actually, when we get it through the Senate.”
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