Tag Archives: New York

How Graham-Cassidy’s Funding Formula Gives Washington Unprecedented Power

The past several days have seen competing analyses over the block-grant funding formula proposed in health-care legislation by Sens. Lindsay Graham (R-SC) and Bill Cassidy (R-LA). The bill’s sponsors have one set of spreadsheets showing the potential allocation of funds to states under their plan, the liberal Center on Budget and Policy Priorities has another, and consultants at Avalere (funded in this case by the liberal Center for American Progress) have a third analysis quantifying which states would gain or lose under the bill’s funding formula.

So who’s right? Which states will end up the proverbial winners and losers under the Graham-Cassidy bill? The answer is simple: Nope.

Policy-makers arguing over minute intricacies of the funding formula miss the fact that the bill gives the executive virtually unlimited discretion to change that funding formula. Whether the statutory formula benefits a given state could well matter less than what federal bureaucrats want to do to tilt the formula in favor of, or against, that state.

While the bill’s proponents claim the legislation will increase state authority, in reality the bill gives unelected bureaucrats the power to distribute nearly $1.2 trillion in taxpayer dollars unilaterally. In so doing, the bill concentrates rather than diminishes Washington’s power—and could set the course for the “mother of all backroom deals” to pass the legislation.

A Complicated Spending Formula

To start with, the bill repeals Obamacare’s Medicaid expansion and exchange subsidies, effective in January 2020. It then replaces those two programs with a block grant totaling $1.176 trillion from 2020 through 2026. All else equal, this set of actions would disadvantage states that expanded Medicaid, because the Medicaid expansion money currently being received by 31 states (plus the District of Columbia) would be re-distributed among all 50 states.

From there the formula gets more complicated. (You can read the sponsors’ description of it here.) The bill attempts to equalize per-person funding among all states by 2026, with funds tied to a state’s number of individuals with incomes between 50 percent and 138 percent of the poverty level.

The bill would adjust the funding formula to reflect both risk adjustment and actuarial value—in laymen’s terms, it would work to ensure that states with sicker-than-average individuals get more funding, and that states that choose to offer richer-than-average benefits don’t draw down excess federal funds as a result. Those adjustments would phase in over several years, with the goal of reaching per-person parity among states by 2026.

Thus far, the formula carries a logic to it. For years conservatives have complained that Medicaid’s match rate formula gives wealthy states more incentives to draw down federal funds than poor states, and that rich states like New York and New Jersey have received a disproportionate share of Medicaid funds as a result. The bill’s sponsors claim that the bill “treats all Americans the same no matter where they live.”

Would that that claim were true. Page 30 of the bill demonstrates otherwise.

The Trillion-Dollar Loophole

Page 30 of the Graham-Cassidy bill, which creates a “state specific population adjustment factor,” completely undermines the rest of the bill’s funding formula:

IN GENERAL.—For calendar years after 2020, the Secretary may adjust the amount determined for a State for a year under subparagraph (B) or (C) and adjusted under subparagraphs (D) and (E) according to a population adjustment factor developed by the Secretary.

In other words, if the secretary of Health and Human Services (HHS) doesn’t like the funding formula, he can change it however he likes. That’s a trillion-dollar loophole that leaves HHS bureaucrats with the ultimate say over how much money states will receive.

The bill does say that HHS must develop “legitimate factors” that affect state health expenditures—so it can’t allocate funding based on, say, the number of people who own red socks in Alabama. But beyond those two words, pretty much anything goes.

The bill says the “legitimate factors” for population adjustment “may include state demographics, wage rates, [and] income levels,” but it doesn’t limit the factors to those three characteristics—and it doesn’t limit the amount that HHS can adjust the funding formula to reflect those characteristics either. If a hurricane like Harvey struck Texas three years from now, Secretary Tom Price would be within his rights under the bill to cite a public health emergency and dedicate 100 percent of the federal grant funds—which total $146 billion in 2020—solely to Texas.

That scenario seems unlikely, but it shows the massive and virtually unprecedented power HHS would have under the bill to control more than $1 trillion in federal spending by executive fiat. To top it off, pages 6 through 8 of the bill create a separate pot of $25 billion to subsidize insurers for 2019 and 2020, and tell the Centers for Medicare and Medicaid Services administrator to “determine an appropriate procedure” for allocating the funds. That’s another blank check of $25,000,000,000 in taxpayer funds, given to federal bureaucrats to spend as they see fit.

In an op-ed over the weekend, former Florida Gov. Jeb Bush (R-FL) rightly criticized Obamacare for “put[ting] enormous power in the hands of a few people in Washington.” But the Graham-Cassidy proposal he endorses would imbue federal bureaucrats with an authority over spending the likes of which Obamacare never even contemplated.

Backroom Deals Ahead

With an unprecedented level of authority granted to federal bureaucrats to determine how much funding states receive, you can easily guess what’s coming next. Unnamed Senate staffers already invoked strip-club terminology in July, claiming they would “make it rain” on moderates with hundreds of billions of dollars in “candy.” Under the current version of the bill, HHS staff now have virtual carte blanche to promise all sorts of “state specific population adjustment factors” to influence the votes of wavering senators.

The potential for even more backroom deals than the prior versions of “repeal-and-replace” demonstrates the pernicious power that trillions of dollars in spending delivers to Washington. Draining the swamp shouldn’t involve distributing money from Washington out to states, whether under a simple formula or executive discretion. It should involve eliminating Washington’s role in doling out money entirely.

That’s what Republicans promised when they said they would repeal Obamacare—to end the law’s spending, not work on “spreading the wealth around.” That’s what they should deliver.

This post was originally published in The Federalist.

Why Lindsay Graham’s “State Flexibility” Plan Falls Short

Shortly after more Republican senators announced their opposition to the current “repeal-and-replace” measure Monday evening, Sen. Lindsey Graham (R-SC) took to Twitter to promote his own health-care plan. He claimed that “getting money and power out of Washington and returning it to the states is the best hope for innovative health care,” adding that such moves were an “antidote to 1-SIZE FITS ALL approach embraced in Obamacare.”

There’s just one problem: Graham’s proposal doesn’t get power out of Washington, and it doesn’t fundamentally change the one-size-fits-all Obamacare approach. It also illustrates moderates’ selective use of federalism in the health-care debate, whereby they want other senators to respect their states’ decisions on Medicaid expansion, but want to dictate to other senators how those senators’ states should regulate health insurance.

Pre-Existing Conditions Are the Problem

A summary of Graham’s proposal claims it would block-grant current Obamacare funds to the states, ostensibly giving them flexibility. But the plan comes with a big catch: “The Obamacare requirements covering pre-existing conditions would be retained.”

When it comes to one of Obamacare’s costliest insurance regulations, Washington would still be calling the shots. That significant caveat echoes an existing waiver program under Obamacare, which in essence allows states to act any way they like on health care—so long as they’re implementing the goals of Obamacare. The Graham plan continues that tradition of fraudulent federalism of Washington using states as mere vassals accomplishing objectives it dictates, but perhaps with slightly more flexibility than under Obamacare itself.

This Is Not Repeal

As I have written before, the repeal debate comes down to an inconvenient truth for many Republicans: They can repeal Obamacare, or they can keep the status quo on pre-existing conditions—but they cannot do both. Keeping the requirements on pre-existing conditions necessitates many of the other Obamacare regulations and mandates, which necessitates subsidies (because otherwise coverage would become unaffordable for most Americans), which necessitates tax increases to pay for the subsidies—and you’re left with something approaching Obamacare, regardless of what you call it.

There’s no small amount of irony in moderates’ position on pre-existing conditions. Not only is it fundamentally incongruous with repeal—which most of them voted for only two years ago—but it’s fundamentally inconsistent with their position on Medicaid expansion as well. Why do senators like Lisa Murkowski want to protect their states’ decisions to expand Medicaid, yet dictate to other states how their insurance markets should function, by keeping regulation of health insurance at the federal level?

True Federalism the Solution

If senators—whether Graham, Murkowski, or others—want to promote federalism, then they should actually promote federalism. That means repealing all of the Obamacare mandates driving up premiums, and letting states decide whether they want to have Obamacare, a free-market system, or something else within their borders.

After all, New York did an excellent job running its insurance market into the ground through over-regulation well before Obamacare. It didn’t even need a guide from Washington. If states decide they like the Obamacare regulatory regime, they can easily re-enact it on the state level. But Washington politicians shouldn’t presuppose to arrogate that power to themselves.

In 1947, the McCarran-Ferguson Act codified a key principle of the Tenth Amendment, devolving regulation of health insurance to the states. Barring a few minor intrusions, Washington stayed out of the health insurance business for more than six decades—until Obamacare. It’s time to bring that principle of state regulation back, by repealing the Obamacare insurance regulations and restoring state sovereignty. Graham has the right rhetoric. Now he just needs the policy deeds to match his words.

This post was originally published at The Federalist.

On Health Care Bill, Federalism to the Rescue

Temporary setbacks can often yield important knowledge that leads to more meaningful accomplishments—a lesson senators should remember while pondering the recent fate of their health-care legislation. This past week, frictions caused by federalism helped create the legislative stalemate, but the forces of federalism can also pave the way for a solution.

Moderates opposed to the bill raised two contradictory objections. Senators whose states expanded Medicaid lobbied hard to keep that expansion in their home states. Those same senators objected to repealing all of Obamacare’s insurance mandates and regulations, insisting that all other states keep adhering to a Washington-imposed standard.

But those Washington-imposed regulatory standards have prompted individual insurance premiums to more than double since Obamacare first took effect four years ago. While the current draft of the Senate bill allows states to waive out of some of those regulations, it outright repeals none—repeat, none—of them.

The High Prices Are The Fault of Too Many Rules

As the Congressional Budget Office score of the legislation indicates, the lack of regulatory relief under the bill would create real problems in insurance markets. Specifically, CBO found that low-income individuals likely would not purchase coverage, because such individuals would face a choice between low-premium plans with unaffordable deductibles or low-deductible plans with unaffordable premiums.

The budget analysts noted that this affordability dilemma has its roots in Obamacare’s mandated benefits package. Because of the Obamacare requirements not repealed under the bill, insurers would be “constrained” in their ability to offer plans that, for instance, provide prescription drug coverage or coverage for a few doctor visits before meeting the (high) deductible.

CBO concluded that the waiver option available under the Senate bill would, if a state chose it, ease the regulatory constraints on insurers “at least somewhat.” But those waivers only apply to some—not all—of the Obamacare regulations, and could be subject to changes in the political climate. With governors able to apply for—and presumably withdraw from—the waiver program unilaterally, states’ policy decisions could swing rapidly, and in ways that exacerbate uncertainty and instability.

If You Want Obamacare, You Can Enact It at the State Level

The Senate should go back to first principles, and repeal all of the Obamacare insurance regulations, restoring the balance of federalism under the Tenth Amendment, and the principle of state regulation of insurance that has existed since Congress passed the McCarran-Ferguson Act in 1947. If Obamacare is as popular as its supporters claim, states could easily reprise all its regulatory structures—as New York, New Jersey, and others did before the law’s passage. Likewise, senators wanting their colleagues to respect their states’ wishes on Medicaid expansion should respect those colleagues’ wishes on eliminating the entire Obamacare regulatory apparatus from their states.

On Medicaid, conservatives have already granted moderates significant concessions, allowing states to keep their expansions in perpetuity. The controversy now stems around whether the federal government should continue to keep paying states a higher federal match to cover childless adults than individuals with disabilities—a proposition that tests standards of fairness and equity.

However, critics of the bill’s changes to Medicaid raise an important point. As CBO noted, states “would not have additional flexibility” under the per capita caps created by the bill to manage their Medicaid programs. Without that flexibility, states might face greater pressure to find savings with a cleaver rather than a scalpel—cutting benefits, lowering reimbursement rates, or restricting eligibility, rather than improving care.

Several years ago, a Medicaid waiver granted to Rhode Island showed what flexibility can do for a state, reducing per-beneficiary spending for several years in a row by better managing care, not cutting it. When revising the bill, senators should give all Medicaid programs the flexibility Rhode Island received from the Bush administration when it applied for its waiver in 2009. They should also work to ensure that the bill will not fiscally disadvantage states that choose the additional flexibility of a block grant compared to the per capita caps.

If senators’ desire to protect their home states helped prompt this week’s legislative morass, then a willingness to allow other senators to protect their home states can help unwind it. Maintaining Obamacare’s regulatory structure at the federal level, while cutting the spending and taxes used to alleviate the higher costs from that structure, might represent the worst of all possible outcomes—an unfunded mandate passed down to millions of Americans. By contrast, eliminating the Washington-based regulatory apparatus and giving states a free choice whether to re-impose it would represent federalism at its best.

This post was originally published at The Federalist.

Has Obamacare Enrollment Peaked?

Has the effort peaked to sign up uninsured Americans for coverage? The announcement that the nonprofit organization Enroll America is laying off staff and redirecting its focus in the face of funding cuts comes amid inconsistent sign-ups during the second Affordable Care Act open-enrollment period and concerns about affordability.

A recent New York Times analysis compared Kaiser Family Foundation estimates of potential enrollees with sign-up data from the Department of Health and Human Services. While some states that signed up few people in 2014 recovered during the 2015 open enrollment, other states lagged: “California, the state with the most enrollments in 2014, increased them by only one percentage point this year, despite a big investment in outreach. New York improved by only two percentage points. Washington’s rates are unchanged.”

Most states could not post consistent gains in both open-enrollment periods. An official from Avalere Health, a consulting firm, told the Times that she was “starting to wonder if we’ve overestimated the whole thing.”

A recent analysis from Avalere Health demonstrates why the enrollment push may have peaked. The percentage of eligible Americans signing up drops off significantly as income rises and federal subsidies phase out, suggesting that absent subsidies Americans find the exchange insurance products unaffordable or of little value. And if the carrot of federal subsidies has not resulted in expected enrollment, the stick—the mandate to purchase insurance—seems even less effective: The special open-enrollment period to accompany this year’s tax-filing season has resulted in 36,000 sign-ups in the 37 states using HealthCare.gov. But 4 million to 6 million people are expected to pay the mandate tax.

The Congressional Budget Office (CBO) estimates that ACA enrollment will average 11 million individuals, with 8 million receiving subsidies. So far, enrollees reporting incomes above the threshold for subsidies are only 2% of uninsured individuals who have signed up, making it hard to see how the administration can reach CBO’s estimate of 6 million unsubsidized exchange enrollees in 2016. The fact that California, New York, and Washington state achieved only marginal enrollment improvements from 2014 to 2015 does not bode well for achieving CBO’s target of 15 million subsidized enrollees next year—a more than 50% increase from the 9.9 million individuals who qualified for subsidies in 2015.

With outreach efforts scaling back, and many Americans uninterested in ACA coverage absent hefty federal inducements, CBO’s estimate of 21 million enrollees next year seems unlikely to be met. If this year’s results from California and New York are any indication, a good question may be whether 2016 enrollment will grow at all.

This post was originally published at the Wall Street Journal’s Think Tank blog.

Harvard and “Free” Health Care

New York Times article earlier this week on changes to Harvard University’s health plan has drawn attention from all sides of the political spectrum. While New York magazine’s Jonathan Chait asserts that the developments at Harvard show the growth of conservative principles, one could also argue they demonstrate the inability of a liberal approach to health plan design to control costs.

The changes at Harvard, which have prompted pushback from many faculty, include the introduction of a $250 deductible and other cost-sharing—i.e., coinsurance and co-payments—for doctor visits, hospitalizations, and certain other procedures. The Times article, quoting the university’s enrollment guide, blames Obamacare as one of the culprits for the changes:

The university said it “must respond to the national trend of rising health care costs, including some driven by health care reform,” in the form of the Affordable Care Act. The guide said that Harvard faced “added costs” because of provisions in the health care law that extend coverage for children up to age 26, offer free preventive services like mammograms and colonoscopies and, starting in 2018, add a tax on high-cost insurance, known as the Cadillac tax.

Some on the right have seized on the irony of the Harvard faculty—many of whom, the Times notes, supported the health care law, and worked to aid its passage—complaining about its ramifications on their own coverage. But the larger irony is that the supposed benefits of the law do not come without costs—that the “free preventive services” discussed in the article and often touted by Obama administration officials really aren’t free. Those costs just get shifted elsewhere, as in the new cost-sharing just announced.

Many on the left firmly believe in health insurance as prepaid health care—that policies should cover all procedures free, or nearly free, of charge. But decades of rising costs have forced many businesses to alter their health plans, adding cost-sharing provisions and in many cases empowering patients to serve as better health care consumers. In many cases these reforms, such as Health Savings Accounts (HSAs), have worked to reduce health costs; a 2012 Health Affairs study found that expanded HSA usage could lower health spending by as much as 9.1%. It’s these principles to which Harvard has turned—at least in part because the mandates in Obamacare left them few remaining options.

Still, Harvard’s new $250 deductible is quite modest compared with that of many other employers. A recent Kaiser Family Foundation report found the average deductible last year exceeded $1,200 for single coverage.

Mr. Chait argues that the Harvard story shows that Obamacare promotes conservative principles when it comes to patient cost-sharing. But he avoids mentioning the obvious: Harvard included such “reforms” only when it had no other choice—because the liberal premise of “free” health care proved too costly to sustain.

This post was originally published at the Wall Street Journal’s Think Tank blog.

Why You CAN’T Keep Your Current Coverage

In case you hadn’t seen it, the Galen Institute yesterday released a new paper discussing the havoc Obamacare is wreaking on insurance markets, and specifically the insurance many Americans had – and liked – before the massive 2700 page law was passed.  The paper includes the most comprehensive collection I have seen of anecdotes regarding insurance carriers who have dropped out of some markets, or gotten out of the health insurance industry completely, since Obamacare passed.  Below are the relevant excerpts from the Galen paper that tell the tale of Obamacare’s woes (I’ve edited the below lightly for length and by replacing citations with hyperlinks).  The complete list of companies that have dropped out of the insurance market shows the breathtaking scope of the impact this massive reorganization of health care is having on Americans’ lives.

Three years ago, candidate Obama promised that “you will not have to change plans.  For those who have insurance now, nothing will change under the Obama plan – except that you will pay less.”  And President Obama followed with the same pledge: “If you like your doctor, you will be able to keep your doctor.  Period.  If you like your health care plan, you will be able to keep your health care plan.  Period.  No one will take it away.  No matter what.”  The Galen report once again illustrates how hollow those pledges have proved.
 

The American Enterprise Group announced in October 2011 that it would stop offering non-group health insurance in more than 20 states.  As a result, 35,000 people will lose the health coverage they have now.  The company cited regulatory burdens, including the “medical loss ratio” (MLR) requirements…in explaining its decision to leave the markets.  This means there will be less competition in these 20 states, resulting in higher prices for consumers in many cases.

In New York, Empire BlueCross BlueShield said it will drop in the spring of 2012 health insurance plans covering about 20,000 businesses in the state. Mark Wagar, president and CEO of Empire, said that the company will eliminate seven of the 13 group plans it currently offers to businesses which have two to 50 employees.  The move is expected to have a great and potentially “catastrophic” impact on small businesses in New York, according to James L. Newhouse, president of Newhouse Financial and Insurance Brokers in Rye Brook, NY.  This loss of competition inevitably will lead to higher prices and fewer choices for businesses and their employees.

In Colorado, World Insurance Company/American Republic Insurance Company announced in October 2011 that it is leaving the individual market, citing the company’s inability to comply with insurance regulations.

In Indiana, nearly 10 percent of the state’s health insurance carriers have withdrawn from the market because they are unable to comply with the federal medical loss ratio requirement.  Indiana was hoping to bring the companies back by asking the Department of Health and Human Services (HHS) for a waiver from the rule, but Washington refused in late November 2011 to grant the waiver….

These are the latest in a series of announcements that health insurers are leaving the market as a result of ObamaCare’s edicts.  But there are many more.

The exodus continues

Citizens in states around the country have learned that carriers are leaving markets, largely as a consequence of the combined effect of the health law and state regulations that make it particularly difficult to offer coverage in the small group market.

Principal Financial Group, based in Iowa, announced in 2010 that it would stop selling health insurance, impacting 840,000 people who receive their insurance through employers served by the company.  The company assessed its ability to compete in the new environment created by PPACA and concluded its best course was to stop selling health insurance policies.

Another 42,000 employees of small and midsize employers learned in January 2011 they were losing their health coverage with Guardian Life Insurance Co. of America. The company announced it was leaving the group medical insurance market (it had reached an agreement with UnitedHealthcare to renew coverage for Guardian clients).  Guardian began withdrawing from the medical insurance market in specific states more than a decade ago, and says it would be leaving the market with or without PPACA.

Cigna announced that it is no longer offering health insurance coverage to small businesses in 16 states and the District of Columbia: California, Connecticut, Florida, Georgia, Hawaii, Illinois, Kansas, Missouri, New Hampshire, New York, North Carolina, Ohio, Pennsylvania, South Carolina, Texas, Virginia, and Washington, D.C.

In Colorado, Aetna will stop selling new health insurance to small groups in the state and is moving existing clients off its plans this year, affecting 1,200 companies and 5,200 employees and their dependents.   Aetna also has pulled out of Colorado’s individual market because of concerns about its ability to compete there, dropping 22,000 members.  Aetna also has dropped out of the small-group market in Michigan and several other states.

Since June of 2010, 13 plans have left the health insurance market in Iowa, citing regulatory concerns.

In New Mexico, four insurersNational Health Insurance, Aetna, John Alden, and Principal — are no longer offering insurance to individuals or to small businesses — drying up the market and driving out competition.

In Utah, Humana is ending its participation in the Utah Health Exchange, leaving only three carriers participating in the exchange.

In Virginia, UniCare has eliminated its individual market coverage for about 3,000 policyholders.  And shortly after the health law was enacted in

2010, a new Virginia-based company, nHealth, announced it was closing its doors, saying that the regulatory burdens posed by the health law made it impossible to gain investor support to continue operating.

More Democrat Hypocrisy on Medicare

The Hill reports this morning that several House Democrats filed legislation (H.R. 3519) earlier this week to exempt the entire Medicare program from sequestration under the Budget Control Act.  As a reminder, the Budget Control Act provided that Medicare payment reductions to providers are capped at 2 percent – meaning that the sequestration reductions to Medicare, in both percentage and amount, will be MUCH smaller than the cuts faced by the Defense Department, and even non-defense discretionary programs as well.

What’s most interesting is the rationale behind the legislation:  The bill’s sponsor, Rep. Ed Towns, claimed that “hospitals in New York are already slated to experience $15 billion in Medicare and Medicaid cuts under” Obamacare – and therefore cannot absorb additional reductions under sequestration. (Never mind that hospitals actually agreed to the Obamacare payment reductions as part of a backroom deal with the Administration.)  The message is clear:  Democrats SUPPORT Medicare payment reductions that help create unsustainable new entitlements – but OPPOSE reducing Medicare payments to lower the deficit and bolster Medicare’s solvency.

Recall that Speaker Pelosi recently admitted that “took a half a trillion dollars out of Medicare in [Obamacare], the health care bill” to pay for more unsustainable new entitlements.  This latest development once again illustrates that when it comes to reforming Medicare to save the program, Democrats are focused on scoring political points rather than solving the problem.

Yet Another Unsustainable Program

A Tuesday afternoon quick quiz – what government program are all these quotes talking about?

  • “The money, it seems, is never enough.”
  • “The program’s costs quickly outpaced expectations,” forcing massive new government spending in the middle of a fiscal year.
  • “It cannot continue to grow at this rate,” accounting for a whopping 37% of the budget, up from 21% in 2000 – a near-doubling in just ten short years.
  • It’s “been a so-called budget buster for 25 years.”
  • “If we continue on the same track, it’s a recipe for disaster.”

If you said the health care law, you’d only be half right.  In reality, all the damning quotes above come from a single Boston Globe story about Massachusetts’ troubled Medicaid program, which has needed nearly $600 million in additional cash infusions just since the Commonwealth’s fiscal year started on July 1.  And Massachusetts isn’t alone; the Wall Street Journal reported this morning that New York’s new Governor, Andrew Cuomo, is considering more than $2 billion in reductions to that state’s troubled Medicaid program.

Granted, New York’s Medicaid program has been plagued with allegations of fraud for years, such that cracking down on improper and illegal spending could very well achieve Gov. Cuomo’s savings target.  But at a time when state budgets are already stressed to the breaking point, why is the federal government forcing states to expand their strapped Medicaid programs?  Does the federal government want all states to face the kind of fiscal problems that New York and Massachusetts – two states that expanded their Medicaid programs years ago – are now experiencing?  How will requiring more states to use the same “recipe for disaster” that Massachusetts has cooked up for itself do anything but give struggling taxpayers another bitter pill to swallow?