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Implications of Health Care Reform Proposals

June 30, 2017

CSH is tracking closely the U.S. House and Senate health care debates and considering the portions of the bills that impact vulnerable populations, supportive housing residents and providers, and the needed growth of supportive housing capacity.  With those priorities in mind, we offer the following comparisons of the House Bill, called the American Health Care Act (AHCA), and the Senate Bill, the Better Care Reconciliation Act (BCRA), to the existing Affordable Care Act (ACA).  Stay tuned for updates as the proposals develop.

Bill Comparisons Affordable Care Act House Bill- American Health Care

Act of 2017[1]

Senate Bill- Better Care Reconciliation Act of 2017[2]
Enacted: March 2010 Passed: May 4, 2017 Expected Vote: Mid-July
       
 

 

 

Basic Federal Medicaid Funding Structure

Federal support increases as more people qualify and medical costs rise.  The federal and state governments share the burden based upon an agreed upon ratio. Federal Support is capped at a per person amount.  Anything states spend beyond that amount, the states are responsible for covering the cost.  This change begins in 2020. Federal Support is capped at a per person amount.  Anything states spend beyond that amount, the states are responsible for covering the cost.   This change begins in January 1, 2021.
Base year for Per Capita Caps or Block grants Not Applicable FY2016 Any eight consecutive quarters from CY 2014 through CY 2017.
 
 

 

 

 

Growth rate of Medicaid Funding

Funding grows as enrollment and costs increase. 2018 and 2019 remain the same.  2020 and ongoing, the cap is in place and costs grow at the rate of the Consumer Price Index- Medical +1% (CPI-M+1) for the elderly and the disabled and at CPI-M for children and the remaining adults. All growth rates are lower than how Medicaid costs rise. 2018, 2019 and 2020 remain the same. 2021-2024 the cap begins. Costs grow at rate of Consumer Price Index- Medical +1% (CPI-M+1) for the elderly/ disabled and at CPI-M for children and remaining adults. After 2024, growth rate is standard CPI.  All growth rates are lower than how Medicaid costs historically have risen.
       
Medicaid Expansion Eligibility ACA Expands Medicaid to persons below 138% of the federal poverty level.  32 states and DC have chosen to expand Medicaid.  Federal government pays 95% of costs for the expansion population in 2017, 94% in 2018, 93% in 2019 and 90% in 2020 and beyond. Additional States cannot expand Medicaid after 2017.  If states keep the expansion, the federal funding ratio becomes the same as other populations, rather than the more generous ratio in the ACA. States would face significant fiscal constraints in maintaining the expansion and many would end the expansion.  Eight states have trigger laws that immediately repeal the expansion for their state if the federal contribution decreases. States receive the ACA enhanced match ratio through 2020 for the expansion population.  In 2021, the federal ratio for paying for the expansion population decreases 5% a year, until 2023 when the federal share is 75%. 2024 going forward the expansion population is the same as other populations for the federal share, usually around 50% or higher for poorer states.

 

       
 

 

 

Redetermination (reapplying for Medicaid)

ACA established streamlined enrollment.  States could require redetermination as infrequently as every two years.  ACA allowed presumptive eligibility, so that persons could self-certify for certain facts such as not having assets.  ACA provided assistance in enrollment. For expansion population, eligibility determinations are required every six months.  Burden to prove eligibility shifts back to applicant and at more frequent intervals. For non-elderly, non-disabled populations, states could choose to require eligibility determinations every six months or more frequently.  Burden to prove eligibility shifts back to applicant and at more frequent intervals.
       
 

 

 

Work Requirements

Not discussed in the law.  CMS under the Obama administration rejected requests for work requirements from states indicating they would "undermine access to coverage.”

 

State option to include work requirements. State option to include work requirements.
       
 

 

 

 

Essential Health Benefits

Ten services including behavioral healthcare that all health plans were required to cover.

 

 

States can opt out of covering certain services for the expansion population with no standards for states to meet regarding what is required to qualify as coverage. States can opt out of covering certain services for the expansion population with no standards for states to meet regarding what is required to qualify as coverage.
       
 

 

 

 

 

 

Can providers bill retroactively?

Historically and in ACA, providers can bill retroactively for 90 days pre-eligibility determination date.  For people experiencing homelessness who are eligible but not enrolled, this allows the possibility for providers to bill for up to 90 days of services and engagement prior to eligibility determination, as they encourage people to sign up for benefits. On October 2nd, 2017, the bill ends ability of providers to bill retroactively for 3 months prior to eligibility determination. This will financially hurt providers who provide services to populations that need to be engaged or need assistance in applying, such as people experiencing homelessness. On October 2nd, 2017, the bill ends ability of providers to bill retroactively for 3 months prior to eligibility determination. This will financially hurt providers who provide services to populations that need to be engaged or need assistance in applying, such as people experiencing homelessness.
       
 

 

 

CBO Score on coverage losses

CBO scored the ACA prior to becoming law and the CBO accurately predicted the coverage gains as measured after ACA was implemented 14 million more uninsured in next year, 23 million would lose coverage by 2026. Approximately 4 million Medicaid recipients to lose coverage in 2018[3], 14 million fewer Medicaid recipients by 2026. 15 more uninsured in next year, 22 million would lose insurance by 2026. Medicaid enrollment would fall by 4% in 2018, and would fall by 16% by 2026.[4]

 

[1] https://www.congress.gov/bill/115th-congress/house-bill/1628/

[2] https://www.budget.senate.gov/bettercare

[3] https://www.cbo.gov/system/files/115th-congress-2017-2018/costestimate/hr1628aspassed.pdf    p.19

[4] https://www.cbo.gov/system/files/115th-congress-2017-2018/costestimate/52849-hr1628senate.pdf p.47

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Implications of Health Care Reform Proposals



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