SABOTAGE Ongoing Federal State Assaults on Americans Health

SABOTAGE! Ongoing Federal & State Assaults on Americans’ Health Care Gordon Bonnyman Tennessee Justice Center April 18, 2017 1

GOP Health Policy Goals 2

Goals of Speaker Ryan & Pres. Trump – Wealth transfers, via tax reform, from lower & moderate to higher income & corporations – Disinvestment in health >>> Investment in military – [Federal deficit reduction] – Important for Ryan, not so important for Trump. 3

The Targets • Affordable Care Act (“Obamacare”) • Medicaid • Children’s Health Insurance Plan (“CHIP”), known in TN as “Cover. Kids” • Federal health care block grant programs (e. g. , NIH funding) • [Medicare – Ryan target; President says it is off the table] 4

Target: Obamacare • Passed in 2010 after 18 months of hearings and negotiations. • Capped a century of bipartisan struggle to enact national health reform. • “Triple Aim” of the law: – Approach universal coverage – Control cost – Improve quality 5

Target: Obamacare • Reversed three decades of federal policy, dating to the election of President Reagan, that have widened the income & wealth gaps and eroded financial security of ordinary families. • The ACA’s taxes on higher income taxpayers, which helped finance insurance subsidies and consumer safeguards, shifted $$ from wealthy to middle and lower income households. 6

Target: Medicaid • Nation’s largest entitlement program. • Medicaid is more efficient and lower cost than other third party payers. But it is still growing due to health care inflation and is seen by the Right as a culprit fueling the federal deficit. • For that reason, and because it benefits the poor, dismantling Medicaid has been the Holy Grail for the Right since Reagan era. • Medicaid reform is Ryan’s single most important budget objective. 7

Target: Medicaid • Medicaid is no longer only a poor people’s program but is integral to healthcare infrastructure that benefits middle & higher income Americans. • Medicaid is regarded favorably by majority of Americans. • Medicaid plays crucial role in state government budgets. 8

Target: CHIP (“Cover. Kids”) • Traditionally a bipartisan program with solid GOP establishment support. • As a government program, it is now targeted by right wing of the GOP. • CHIP must be reauthorized by September, which makes it vulnerable. Likely to become hostage to compel concessions from Democrats and moderate GOP members on, e. g. , ACA repeal or Medicaid “reform. ” 9

Target: Federal Block Grants • President’s budget would cut NIH and range of discretionary block grant programs that support health and research. • Those programs have bipartisan support but are vulnerable as bargaining chips. 10

Present political status 11

The Opening Battle • The American Health Care Act, sponsored by House Speaker Paul Ryan, would gut Obamacare and cap federal funding for Medicaid. • CBO projected an increase of 24 M uninsured. • AHCA would have shifted $880 B in costs from federal govt. to the states. It would have cost TN’s state budget $500 M/year. 12

The Opening Battle • If 23 of GOP’s 237 House members vote with the 193 Democrats, AHCA cannot pass. • Enormous grassroots opposition from Right and Left, only 17% in favor of AHCA. • Ryan made concessions to right wing Freedom Caucus, but that alienated more moderate GOP members. • On March 24 th, after intense negotiations involving Pres. Trump, Speaker Ryan withdrew the bill from consideration. 13

Zombie Trumpcare? • Rumors have persisted of efforts to bridge divide within the GOP caucus, but not clear if they can bring AHCA back from dead, OR • Will Congress simply find another vehicle for undoing ACA and capping Medicaid? 14

Why GOP Cannot Let ACA Repeal & Medicaid “Reform” Stay Dead • Congressional members are afraid of being defeated in 2018 GOP primaries for failing to deliver on their repeated vows to repeal the ACA. • They have to go after Medicaid to get $$$ needed to pay for defense build-up and tax cuts for wealthy and for corporations. 15

Looming threats 16

Congressional Attacks • “Choke points” in coming months where the Right can try to force moderates to make concessions re. ACA repeal or Medicaid cuts: – Raising the debt ceiling – needed by July-ish. – Reauthorization of CHIP – expires in September. • “Carrots & Sticks” for various interest groups to support repeal or Medicaid cuts: – Increase short term funding for states, hospitals, etc. – Threaten drug industry with price controls, etc. 17

Congressional Attacks • Renewed high profile frontal attack like the AHCA: – Freedom Caucus says closer to deal; – President is using cost-sharing reductions (CSRs) for moderate income families as bargaining chip; – Could come up in early May. 18

Congressional Attacks • Alternatively, resort to old fashioned tactic of “death by a thousand cuts” using technical amendments by, e. g. : – Changing Medicaid state funding rules. – Denying funding for cost-sharing reductions (CSRs) 19

“Follow the Money” No matter: • What Congress promises, or • How they package their proposals, The proof is in the Congressional Budget Office (CBO) scoring and the projected effects on insurance and savings. REMEMBER: Their goal is to take money out of health care system and away from lower income households. 20

SABOTAGE! • Just by threatening to cripple the ACA by executive orders, rule changes and refusal to enforce, Congress and Trump Administration destabilize insurance markets. • Insurers exit. • ACA Marketplace “explodes, ” as President predicts. 21

SABOTAGE! TN legislature’s continuing refusal to accept federal funds to close the coverage gap, as envisioned in the ACA: • Leaves 280, 000 working Tennesseans uninsured • dooms rural and safety-net hospitals, and • undermines insurance Marketplace. 22

What’s at stake 23

Ryan/Trump Goals Remain Same • End of ACA, resulting in 24 M more uninsured. • Nearly $1 Trillion in Medicaid savings over next decade. • Elimination of the ACA’s consumer protections, civil rights requirements and insurance company regulations. 24

Medicaid: Per Capita Caps • Per enrollee limits on federal payments to states. • This shifts costs to states, consumers & health care providers. • Makes inequities among states permanent, to the disadvantage of TN and Tennesseans. 25

What does this mean for Tennessee? • 526, 000 Tennesseans stand to lose health coverage. • Ends Medicaid expansion, keeps TN from joining 31 states that have expanded coverage under the ACA, leaves 280, 000 still uninsured. • Widens income inequality 26

Medicaid cuts affect TN’s Healthcare Infrastructure • 1. 5 M Tennesseans rely on Tenn. Care for coverage. • 61% of nursing home care is covered by Tenn. Care. • Over half of births and half of all TN children are covered by Tenn. Care. • 37 hospitals are at risk of closing and are highly dependent on Medicaid funding. 27

Medicaid cuts affect TN’s WHOLE State Budget • Over 20¢ of ever dollar in state budget is federal Medicaid funding. • Proposed federal Medicaid cuts of $500 M per year, increasing in future years, are too big to handle just with Tenn. Care cuts. • ALL aspects of the state budget, including K-12 and higher ed, will sustain cuts. 28

TN’s Congressional Delegation 29

Senator Alexander • Heads important Health, Education, Labor & Pensions (HELP) Committee • Supported AHCA and said it could go to Senate floor without committee hearings. • Advocates for Medicaid spending cuts. • Supports ACA “repair. ”

Senator Corker • Has pressed in the past for Medicaid cuts but was more moderate on the AHCA. • Generally follows Sen. Alexander’s lead on health matters.

Health Care Options Act • Many counties in East TN now down to one Marketplace insurer & maybe none in 2018. • Senators Corker & Alexander offered the Health Care Options Act to provide subsidies for coverage bought outside the Marketplace. • Experts warn it could reward bad insurers and incentivize more insurers to exit Marketplace. • Can’t counter other GOP efforts to sabotage ACA. • Useful if it leads to bipartisan effort to find pragmatic solutions. 32

Contact BOTH Senators City Senator Lamar Alexander Chattanooga Joel E. Soloman Federal Building 900 Georgia Avenue, #260 Chattanooga, TN 37402 Phone: (423) 752 -5337 Jackson 111 Murray Guard Drive, Suite D Jackson, TN 38305 Phone: (731) 664 -0289 33 Senator Bob Corker 10 West MLK Blvd. , 6 th Floor Chattanooga, TN 37402 Phone: (423) 756 -2757 91 Stonebridge Boulevard Suite 103 Jackson, TN 38305 Phone: (731) 664 -2294 Knoxville Howard H. Baker, Jr. , U. S. Courthouse 800 Market Street, #112 Knoxville, TN 37902 Phone: (865) 545 -4253 800 Market Street, Suite 121 Knoxville, TN 37902 Phone: (865) 637 -4180 Memphis Clifford Davis-Odell Horton Federal Building 167 North Main Street, #1068 Memphis, TN 38103 Phone: (901) 544 -4224 100 Peabody Place, Suite 1125 Memphis, TN 38103 Phone: (901) 683 -1910 Nashville 3322 West End Avenue, #120 Nashville, TN 37203 Phone: (615) 736 -5129 3322 West End Ave. , Suite 610 Nashville, TN 37203 Phone: (615) 279 -8125 Tri-Cities Regional Airport 2525 Highway 75 Suite 101 Blountville, TN 37617 Phone: (423) 325 -6240 1105 East Jackson Boulevard Suite 4 Jonesborough, TN 37659 Phone: (423) 753 -2263

TN’s GOP House Members To reach your Member of the House of Representatives: • Call 1 -866 -426 -2631. • Then enter your zip code to be connected to your House member. 34

The Message • Tell them to “repair” the ACA and protect Medicaid. • Honor President Trump’s pledge to make health coverage more affordable for all Americans. • Don’t let Congress sabotage our health care. 35

Join the National Day of Action! 36

National Day of Action! Tomorrow (April 19), join hundreds of thousands of concerned Americans in taking action to defend health care. Call Senator Lamar Alexander (615 -736 -5129), Senator Bob Corker (615 -279 -8125) and your Congressman (866 -426 -2631). 37

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Questions? 40