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September 22, 2017

The 50+ provider, hospital, and insurer groups speaking out against the Graham-Cassidy bill

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As the Senate gears up to vote on a GOP bill (HR 1628) to repeal and replace major parts of the Affordable Care Act (ACA) and overhaul Medicaid, industry stakeholders—including hospital, provider, patient, and insurer groups—are nearly unanimous in opposing the measure, and think tanks on both sides of the political spectrum are voicing concerns, Vox reports.

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Senate Majority Leader Mitch McConnell's (R-Ky.) office on Wednesday announced that the Senate intends to vote next week on the bill, proposed by GOP Sens. Lindsey Graham (S.C.) and Bill Cassidy (La.). Among other provisions, the bill would repeal the ACA's individual and employer coverage mandates; loosen ACA protections for individuals with pre-existing conditions; turn traditional Medicaid into a per capita cap program; and repeal the ACA's Medicaid expansion and put in place new state block grants for federal health care funding.

If the Senate proceeds with a vote, it will do so without a full score from the Congressional Budget Office (CBO). CBO on Monday said it will provide lawmakers with some basic budgetary estimates, but it will not be able to project how the bill would affect the uninsured rate or premiums before the Sept. 30 deadline to pass the bill under current budget reconciliation instructions. Without a CBO score, it is difficult to know how the bill would affect the uninsured rate, premium rates, and market stability.

Provider groups react

According to Business Insider, numerous provider groups have come out against the proposed bill.

For instance, American Medical Association CEO James Madara in a letter to Senate leaders wrote, "We believe the Graham-Cassidy amendment would result in millions of Americans losing their health insurance coverage, destabilize health insurance markets, and decrease access to affordable coverage and care."

American Academy of Pediatrics President Fernando Stein in a statement said that while "the bill may be disguised under a different name, ... it contains the same dangerous policies as the legislation that failed to advance out of the Senate earlier this summer" and "goes even further in its attacks on Medicaid."

Jack Ende, president of the American College of Physicians (ACP), in a letter sent to Graham and Cassidy wrote, "We believe that the substantial cuts to Medicaid authorized by this legislation would cause a significant increase in the number of uninsured patients and that it would undermine essential benefits provided for patients insured under current law."

The Association of American Medical Colleges President and CEO Darrell Kirch in a letter also urged senators to reject the bill. "Under this legislation, the number of uninsured patients nationwide will increase dramatically and important existing patient protections will be at risk," Kirch wrote.

Planned Parenthood, which would receive no federal funding under the bill, also opposed the bill, saying, "It blocks women from getting preventive care at Planned Parenthood. It slashes Medicaid, which one in five women of reproductive age rely on for care, including birth control and cancer screenings. It guts essential health benefit protections, including maternity coverage and prescription drugs. Thirteen million women could lose coverage to maternity care under this bill. And it raises premiums on millions more by eliminating tax credits."

Other provider groups that have spoken out against the bill include the American Academy of Family Physicians, the American College of Obstetricians and Gynecologists, the American Nurses Association, the American Osteopathic Association, the American Psychiatric Association, the American Public Health Association, the National Institute for Reproductive Health, and National Nurses United.    

Hospital groups voice concerns

Separately, American Hospital Association President Rick Pollack said the bill "would erode key protections for patients and consumers."

Federation of American Hospitals President and CEO Chip Kahn on Wednesday said the bill "could disrupt access to health care for millions of the more than 70 million Americans who depend on Medicaid and the marketplaces for their health coverage," adding, "We urge the Senate to reject legislation that fails to move us forward in assuring Americans access to affordable health care and coverage."

America's Essential Hospitals President and CEO Bruce Siegel in a statement also condemned the measure. "Throughout this year's health care debate, America's Essential Hospitals stood by its position that policy changes must maintain coverage for those who have it, preserve access, and protect hospitals that care for low-income and other vulnerable people," Siegel said. "While we do not yet have a [CBO] score for the Graham-Cassidy proposal, the plan appears to violate those core principles."

Cleveland Clinic CEO Toby Cosgrove similarly expressed concerns about the bill, saying it could "threaten the financial viability of a lot of hospitals across the country." Citing the lack of a CBO analysis, Cosgrove added, "This [bill] has not gotten the chance to be widely vetted, nor do we know for sure how the bill is continuing to change."

Meanwhile, the Children's Hospital Association said the proposal "would have devastating consequences for children and families."  Several other hospital organizations, at the federal and state level, have also spoken out against the measure, including the Greater New York Hospital Association, the Kansas Hospital Association, and Lutheran Services in America.

Health insurers push back on proposal

Although it remained largely silent on previous repeal-and-replace proposals, America's Health Insurance Plans (AHIP) has come out against the Graham-Cassidy bill. AHIP President and CEO Marilyn Tavenner wrote in a letter to lawmakers, "[The Graham-Cassidy bill] would have real consequences on consumers and patients by further destabilizing the individual market; cutting Medicaid; pulling back on protections for pre-existing conditions; not ending taxes on health insurance premiums and benefits; and potentially allowing government-controlled, single payer health care to grow."

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In a statement, the Blue Cross Blue Shield Association also criticized the bill, saying it would "reduc[e] funding for many states significantly and would increase uncertainty in the marketplace, making coverage more expensive and jeopardizing Americans' choice of health plans."

Kaiser Permanente in a statement said the bill's provision on block grants would "erode coverage of needed medical services and pose major issues for state budgets," while its repeal of the individual mandate "without alternative incentives for enrollment will lead to fewer people enrolled and higher premiums."

Separately, Alliance of Community Health Plans (ACHP) President and CEO Ceci Connolly in a letter to Senate leadership wrote that the measure would "significantly impact the health of our communities, hurting our neighbors, friends, and employees." ACHP added, "It puts in jeopardy the coverage gains won over the past few years and the critical consumer safeguards provided by essential health benefits and protections afforded by a ban on pre-existing conditions."

Margaret Murray, CEO of the Association of Community Affiliated Plans, said news of the latest bill comes as a disappointment because the association "thought Congress was finally making progress toward bipartisan solutions on stabilizing the market and reauthorizing CHIP."

Patient and advocacy groups voice concerns

AARP EVP Nancy LeaMond in a statement on Tuesday also condemned the bill, saying it would increase costs for older U.S. residents, cut coverage, and undermine protections for consumers with pre-existing conditions. Further, citing the lack of a CBO analysis or congressional hearings on the bill, LeaMond said, "It is irresponsible for the Senate to take a vote on a bill impacting tens of millions of Americans and one-sixth of our nation's economy without information on the potential consequences."

Claire McAndrew, director of campaign strategy for Families USA, said, "We are working with our state partners across the country to make sure members of Congress don't vote for a proposal to slash funding for consumer protections and funding for Medicaid and marketplace subsidies." 

Separately, a group of 16 patient and provider groups—including the ALS Association, the American Cancer Society Cancer Action Network, the American Diabetes Association, the American Heart Association, March of Dimes, and the American Lung Association—in a letter expressed their opposition to the bill. "Affordable, adequate care is vital to the patients we represent," the groups wrote. "This legislation fails to provide Americans with what they need to maintain their health. In fact, much of the proposal just repackages the problematic provisions of the Better Care Reconciliation Act (BCRA), which we opposed."

Similarly, the Alzheimer's Association, the Alzheimer's Impact Movement, The Arc, the Arthritis Foundation, the Coalition to Stop Opioid Overdoses, the Consortium for Citizens with Disabilities, the Cystic Fibrosis Foundation, the Consumers Union, Family Voices, the HIV Medicine Association,  JDRF, the National Coalition for Cancer Survivorship, the National Health Council, the National Multiple Sclerosis Society, the National Organization for Rare Diseases, and WomenHeart voiced concerns about the measure.

Think tanks, government associations

The bill also drew criticism from the conservative Heritage Action for America. The group's CEO, Michael Needham, in a statement said, "Based on what we know right now, Graham-Cassidy would make some improvements over the status quo but it would not actually deliver on the Republicans' seven-year campaign promise to repeal and replace Obamacare."

Georgetown University's Center for Children and Families criticized the bill, saying the measure, "like the previous Senate 'repeal and replace' proposals, takes a fiscal crowbar to Medicaid's knees."

Robert Wood Johnson Foundation President and CEO Richard Besser in a statement said, "The United States Senate may consider legislation as early as next week that could result in dramatic damage to the nation's health care safety net. This is simply bad for health." He added, "This is not the right future for our country."

Separately, the National Association of Medicaid Directors on Thursday expressed concerns that the bill would impose too great a burden on states. "The scope of this work, and the resources required to support state planning and implementation activities, cannot be overstated," the group said. "States will need to develop overall strategies, invest in infrastructure development, systems changes, provider and managed care plan contracting, and perform a host of other activities," and the "vast majority" of states could not do that within the bill's two-year timeframe (Kliff, Vox, 9/20; Diamond, Politico, 9/20; Finnegan/MacDonald, FierceHealthcare, 9/20; Meyer, Modern Healthcare, 9/18; AAMC letter, 9/19; Swanson, Vox, 9/21; Ramsey, Business Insider, 9/21; King, Washington Examiner, 9/21; Hamblin, The Atlantic, 9/21; Small, FierceHealthcare, 9/20; Young, Huffington Post, 9/20; ACP letter, 9/13; Kaiser Permanente statement, 9/20; AARP statement, 9/19; American Heart Association et al. letter, 9/18; Heritage Action Foundation release, 9/13; Fox, CNBC, 9/21; Andy Salvitt tweet, 9/21).

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