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Major points and what they mean

Week 3 - Affordable Care Act - Repeal
The Affordable Care Act (ACA, or "Obamacare") changed healthcare in many ways. It let states offer Medicaid (Medi-Cal in California) coverage to more people, and gives 90 cents on the dollar if they do. It makes nearly all individuals have health insurance (the "individual mandate"), and gives subsidies depending on income. Simultaneously, it prevents insurance companies from rejecting applicants due to a pre-existing condition.

A number of the ACA's concepts came from the conservative Heritage Foundation, in a response to other, Democratic proposals being advanced in the early 1990s. However, from its inception and introduction by President Obama, Republicans have been opposed to it for strategic and policy reasons. 


Repeal - The Actions
With Republicans soon in control of the House, Senate, and White House, repealing the ACA is understandably but incorrectly seen as coming just around the corner. In truth, both the technical act of a full repeal, and the political considerations at play, are surprisingly complex.

To actually repeal the ACA, Republicans have started by using "budget reconciliation" as the vehicle for this. It needs only a simple majority vote. In the Senate, this will make passing a repeal easier for Republicans. They will not need Democratic support to pass the 60-vote threshold normally needed to override filibusters and other delays. But reconciliation can only address parts of the ACA that impact the federal budget. For example, this includes the Medicaid expansion and the individual mandate, but not the pre-existing condition requirements. This, like many other provisions not included in a reconciliation repeal, have broad and bipartisan support. But all these elements interlock.

One problem created by this interlock is seen in efforts to end the individual mandate (which Republicans oppose) and still requiring insurers to provide coverage (which Republicans and Democrats support). This creates the potential for a "death spiral." In such a spiral, healthy people drop their coverage, since they can sign up later. Insurers, making less money, have to raise premiums - which prompts more (healthy) people to drop their coverage.

To mitigate against this, one potential proposal is a "continuous coverage" mandate, keeping the pre-existing conditions protection only if an individual has kept continuous coverage for a period of time. This is just one of a number of problems with using budget reconciliation to repeal (parts of) the law. Its interdependent parts make it very hard to change any one part without considering all of them. 


Repeal - The Impact
To encourage states to expand Medicare coverage, the ACA provided federal reimbursements. The final level, of 90%, is still far above many other federal matching fund rates. In California, the state's current Budget is $266.8 billion. Of that, well over one-third ($95.9B) of all funds (not just healthcare) comes from federal sources. The developmental disabilities services system is receiving over $2.5B in federal funds.

Any repeal that lowers federal funding could have impact on our system. Even if developmental services was untouched, funding reductions in other areas would have to be either be tolerated or replaced with state funds. Those funds would come from other programs.

Additionally, many people in our system are Medi-Cal eligible. California's ACA-mandated Medi-Cal expansion, per a UCLA Center for Health Policy Research Policy Note, "is likely to have significantly increased coverage for California'a uninsured developmentally disabled population."  Any repeal of the Medicaid expansion could cause many low-income adults and families to lose eligibility. This would push the cost of developmental services back on regional centers (as "payers of last resort"). With the loss of federal funds, this could potentially spike our system's costs to the state's General Fund.  


Repeal - The Political Considerations
The question of repeal is inextricably linked to replacing the ACA. A number of Republican-led states have already expanded Medicaid coverage via the ACA. Thus, the Senate Committee on Finance is asking for input from the Republican Governors Association. However, the lack of detailed replacement plans with widespread support means that there actually isn't a hard timeline for repeal. House Speaker Paul Ryan has only been willing to say that the "legislating will occur this year,"

This is what is termed the "repeal and delay" strategy, which would allow a quick and purely symbolic repeal of the ACA, but delay the implementation of the actual repeal for some time. This would allow more time for Republicans to develop a replacement plan.

Repeal and delay has its challenges; splitting the acts of repealing and replacing means votes can be lost in between. Legislators who aren't interested in replacement plans have no incentive (i.e., the act of repeal) to vote on a new plan. Even the delay time is a point of contention - some legislators want more time to craft an alternative, while others, having pushed for years to repeal the ACA, are opposed to waiting.

In all circumstances, the Republicans are almost guaranteed to be alone in any repeal. Democrats remain unlikely to provide much assistance in developing a replacement, either.

Next week, we'll be exploring what replacement proposals are being discussed, and what they might mean for us.
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