Affordable Care Act

Trump's Stormtrooper Tactics

Frustrated by the failure of Congress to repeal and replace Obamacare, President Trump has started his own executive war against the health care plan named after his predecessor, which threatens the stability of US health insurance markets.

Frustrated by the failure of Congress to repeal and replace Obamacare, President Trump has started his own executive war against the health care plan named after his predecessor, which threatens the stability of US health insurance markets.

There's a funny myth in movie fan culture: Stormtroopers are poor shots. Despite plenty of easy opportunities to hit Luke Skywalker and his allies, the embarrassingly incompetent Empire troops consistently miss. Instead, they spray the target hoping one of their many shots finds an enemy. Once in a while, a shot finds its mark.

I was thinking of this comparison as I watched President Trump try, and fail, on multiple accounts to erode the foundation of the Affordable Care Act. Despite months of work and two very visible failures in Congress. What Trump hasn't achieved through legislation, he is now trying to do by executive orders. Here, unfortunately for backers of the ACA, is where we see the Stormtrooper hitting his mark. 

Over the past three weeks, Trump has used his executive authority to end critical payments to insurers that allow low-income and vulnerable Americans to afford health care coverage. Trump has cut 90 percent of the advertising and education budget in advance of the November 1 open enrollment period – the time of year when people sign up for health care benefits on the open marketplace created by the ACA. By also shrinking the enrollment period, Trump hopes fewer will sign up, reaffirming his narrative that Obamacare is failing across the nation.

Thankfully in Oregon, the leadership at the Department of Consumer & Business Services anticipated this move and took immediate action to supplement public awareness with $1.8 million in ad buys around the state.  However, it's only a matter of time before Trump pursues yet another shot at derailing the ACA, and we cannot expect state and health care leaders to bail out Oregon every time he strikes.

Trump has many additional tools at his disposal that should frighten Oregonians who value our 95 percent coverage rate and who appreciate the importance of improving access to vulnerable populations – those more likely to forego primary care and end up in the emergency room, costing the state and Oregonians more in the long term.  

Trump could continue to erode enrollment assistance programs and funding across the country, putting barriers between individuals and their health care. The federal Department of Health and Human Services could give states the ability to limit enrollment – including who is covered in a state's ACA expansion – by requiring proof of employment or increasing cost-sharing requirements. Finally, he could put all of his effort behind urging Congress to remove the individual mandate, effectively gutting a key component of the ACA that is providing some semblance of stability for insurers to remain in marketplaces across the country.  

I wish Trump was as poor of a shot as an Imperial Stormtrooper, but recently he's been finding his target way too often. Where's Luke Skywalker and Princess Leia when we need them most?


Dale Penn II, senior public affairs associate, has been deeply involved in government relations and regulatory affairs in Oregon for 10 years. During his work for the 2005 Senate Judiciary Committee, Dale began developing close relationships with key legislators and agency staff across party lines and issue fields.

Latest ACA Repeal Measure Would Punish Oregon

CNN posted a map showing how the latest Senate GOP effort to repeal and replace the Affordable Care Act would affect states such as Oregon and Washington that expanded their eligibility for Medicaid coverage. Other states that are billion-dollar losers under the GOP proposal include California, Ohio, Pennsylvania and Michigan.

CNN posted a map showing how the latest Senate GOP effort to repeal and replace the Affordable Care Act would affect states such as Oregon and Washington that expanded their eligibility for Medicaid coverage. Other states that are billion-dollar losers under the GOP proposal include California, Ohio, Pennsylvania and Michigan.

The US Senate is taking another stab at repealing and replacing the Affordable Care Act (ACA), this time with a plan that could disproportionately hurt the Medicaid programs in Oregon and Washington. Oregon could be one of the hardest hit states, with more than a $3 billion loss over the next decade.

Along with 18 other states ranging from New York to North Dakota, Oregon and Washington expanded Medicaid eligibility under provisions of the ACA. The latest version of the Cassidy-Graham bill in the Senate would effectively scrap discrete federal funding for the expansion as part of a plan to give states Medicaid block grants.

“The revised version of the Cassidy-Graham plan would disproportionately harm certain states,” according to the Center of Budget and Policy Priorities, a nonpartisan research and policy institute that analyzes how federal budget priorities impact low-income Americans. “The block grant would not only cut overall funding for the Medicaid expansion and marketplace subsidies, but also starting in 2021 redistribute the reduced federal funding across states based on their share of low-income residents rather than their actual spending needs.”

The Center says states that expanded Medicaid eligibility, including Oregon and Washington, could end up receiving 35 to 60 percent below what they get now from the federal government under current law. That would exacerbate Oregon’s budgetary challenge if the Medicaid funding package approved in the 2017 legislative session is referred to and rejected by voters in a special election next January.

After a dramatic Senate floor showdown in August that failed to approve a previous GOP proposal to repeal and replace the ACA, it seemed as if congressional Republicans had decided to move on to other issues, including tax reform. The proposal by GOP Senators Bill Cassidy and Lindsey Graham seemed to come out of nowhere and has sparked speculation it could get enough votes to pass.

Senate Republicans only have until September 30 to approve an ACA repeal and replacement measure with 50 votes under complicated budget reconciliation procedures. That means Senate Republicans, who hold a slim 52-member majority, can only afford to lose two of their members on the repeal vote. A 50-50 tie vote would be broken under Senate rules when Vice President Mike Pence cast a vote. The Trump White House has signaled it would support the Cassidy-Graham bill. GOP Speaker Paul Ryan has indicated he would push for House passage.

Opponents say the Cassidy-Graham measure also would destabilize the individual health insurance market by eliminating ACA subsidies and allowing states the flexibility waive essential benefits and weaken the pre-existing condition provisions in the ACA.

“While insurers would still be required to offer coverage to people with pre-existing conditions,” the Center says, “insurers could charge unaffordable premiums of thousands or tens of thousands of dollars per month, effectively resulting in a coverage denial.”

Insurers also could offer plans with large benefit gaps such as maternity care, substance abuse treatment and mental health services, which a Kaiser Family Foundation analysis was a common pattern in health insurance before passage of the ACA.

The impact could be even greater as the Cassidy-Graham bill reduces the per capita allocations in block grants for all states starting after 2026. “Many states would likely cut home and community-based services, which allow people needing long-term services to remain in their homes rather than moving to a nursing home,” according to the Center.

If Senate Republicans are unable to muster the necessary 50 votes for Cassidy-Graham in the next 10 days, then all the dire predictions will be put aside.

Another casualty of Cassidy-Graham has been the bipartisan effort in the Senate Health Committee to find politically acceptable ways to stabilize the individual health insurance marketplace and reduce pressure on higher premiums. Senator Lamar Alexander, the GOP chairman of the committee who was working with Washington Senator Patty Murray, said no consensus was reached. The effort was undercut when Ryan said the House wouldn’t consider a bipartisan stabilization bill.

A group of 10 governors representing Medicaid expansion states sent a letter to Senate leaders urging a continuation of bipartisan efforts on the ACA, saying that the way to “achieve true, last reforms.” One of the governors is John Bel Edwards of Louisiana, which is the home state of Senator Cassidy.

Louisiana Secretary of Health Dr. Rebekah Gee sent a letter directly to Cassidy that said, “In its current form, the harm to Louisiana from this legislation far outweighs any benefits. Therefore, I must register our deep concerns and hope we can find a better path forward toward fixing the broken parts of our healthcare system.

State, Federal Health Care Debates Remain in Flux

Oregon legislative leaders Tina Kotek and Peter Courtney want voters to know the fiscal risks of rejecting a tax package to sustain funding for the Oregon Health Plan, as federal lawmakers begin hearings on ways to stabilize coverage and premiums for the individual health insurance market under the Affordable Care Act.

Oregon legislative leaders Tina Kotek and Peter Courtney want voters to know the fiscal risks of rejecting a tax package to sustain funding for the Oregon Health Plan, as federal lawmakers begin hearings on ways to stabilize coverage and premiums for the individual health insurance market under the Affordable Care Act.

On the same day Oregon lawmakers prepared for a January vote on funding to maintain the Oregon Health Plan, a US Senate committee held the first hearing on how to stabilize the individual insurance markets under the Affordable Care Act. Both reflect the unsettled and unsettling condition of key parts of America’s health care system.

Legislators worked Tuesday on a ballot title for a referral sought by GOP Rep. Julie Parrish that could result in voter rejection of a tax package to sustain current spending levels for the Oregon Health Plan, the state’s Medicaid program.  If the tax package is voted down, state officials could face a budget hole of between $300-$500 million to plug during the short 2018 legislative session that starts next February.

An opinion from Legislative Counsel added more potential confusion to the issue that voters could be asked to decide in a January special election. The opinion says the way the referral is written would only eliminate the additional 0.7 percent assessment on hospitals from October 6, 2017 until January 1, 2018. The referral wouldn’t have any effect on the previously approved hospital assessment.

The draft ballot title clearly attempts to raise the specter of the impact of rejecting the tax package on low-income families, children and insurance premiums.


On Capitol Hill, GOP Senator Lamar Alexander kicked off the first hearing of any kind this year on the Affordable Care Act by declaring, "To get a result, Democrats will have to agree to something – more flexibility for states – that some are reluctant to support. And Republicans will have to agree to something – additional funding through the Affordable Care Act – that some are reluctant to support." Alexander said his priority is on lowering health insurance premiums.

On the day of the hearing, Washington Senator Patty Murray said in an op-ed in The Washington Post that Democrats are willing to work on a bipartisan approach to stabilizing insurance markets. In the op-ed, Murray raised the issue of creating a “public option” to ensure competition to hold down premiums in the individual health insurance market. Capitol Hill observers said that is an unlikely outcome in what already is viewed as a chancy legislative venture in the wake of the Senate’s failed attempts to repeal and replace Obamacare. Conservative groups have already launched a digital ad campaign slamming Alexander’s effort.

A more likely provision may be some kind of reinsurance program to broaden the base to pay for high-cost individuals, which tend to spike overall premium rates.

Alexander expressed hope his committee can produce compromise legislation by the end of September, which is a critical deadline for insurance companies that have to submit plans and prices for individual health insurance markets around the country. Skeptics doubt whether Alexander’s target date is realistic, especially in light of other looming congressional debates to raise the debt limit, approve a disaster relief funding package and approve some kind of FY 2018 appropriation.

For now, the Trump administration is continuing, with reluctance, to make subsidy payments to medical providers as called for by the Affordable Care Act. Insurers have warned that cutting off those subsidies, which essentially compensate for high-cost care for a few individuals, could lead to as much as a 20 percent increase in premiums, effectively forcing some people to drop their policies.

There also isn’t any clear indication how much or perhaps in what form Congress will authorize for Medicaid reimbursement to states in FY 2018. The Obamacare repeal and replacement bill that narrowly cleared the House earlier this year would have slashed $800 billion from federal Medicaid reimbursements over the next 10 years.

Reforms Will Push Up Premiums

Implementation of health care reforms in Oregon and America are beginning, but may occur in the backdraft of rising insurance premium rate shock.At the end of the 2011 and 2012 legislative sessions, headlines crowed about the progress Oregon had made on health care transformation as a result of bipartisan legislation from both sessions. In fact, Oregon has become a national leader on the topic with leadership from Oregon's governor, Dr. John Kitzhaber. From the establishment of Coordinated Care Organizations (CCOs) to the establishment of one of the first exchanges nationwide, Oregon took major steps forward in implementing health care reform.

As CCOs have begun to spring up in different communities throughout the state and details of the health insurance exchange have become more clear, a surprise that legislators didn’t anticipate is beginning to bubble-up to the surface: Major increases in health care costs will hit consumers just as the exchange debuts early next year.

Many of the causes of these cost increases are outside the control of Oregon legislators, but they nonetheless have the potential to unravel public support for reform as front-line consumers come face-to-face with the true cost of health care for the first time. 

Oregon Emphatic on Expanding Medicaid

While some states have debated whether to expand Medicaid as part of implementation of the federal Affordable Care Act, Oregon appears not even to have considered the possibility of saying no.

Led by an activist governor, John Kitzhaber, Oregon has proceeded as if health care reform was a foregone conclusion.  In fact, the governor, a former emergency room physician and one of the country's acknowledged health care policy experts, has taken action to put the state ahead of almost all others, contending there is no choice but to reform a system that could threaten to bankrupt the state budget.

Kitzhaber encouraged the state to develop an online health insurance shopping center before there were any federal rules on such health insurance exchanges. He proposed a new approach to delivering health care to Medicaid recipients through "coordinated care organizations" and prodded the legislature to go along with him. In the new budget Kitzhaber unveiled for 2013-15, he continued moving down the road aggressively toward reform.

Lawmakers, even with a nearly even split between Democrats and Republicans in the 2011 legislative session, went along with the governor in large numbers. The vote on the underpinning of reform, Senate Bill 1580, passed on a party line vote in the Senate, but cleared the House by a wide margin, 53 to 7.

Few legislators went on record with statements in opposition to reform, though a couple Republican voices in the Senate asked whether the state wanted to get linked up with Obamacare when so little was known about long-range costs.

Last week, one Republican said he was concerned that the governor had included Medicaid expansion population in his Oregon Health Plan budget recommendation, exposing the state to unfunded costs down the road.

Meanwhile, other states have moved more slowly than Oregon. An Associated Press story this week reported several governors have resisted submitting to the federal directives.

Banking on Health Care Coordination

A lot rides on the success of health reform ventures such as coordinated care organizations (CCOs), but not everybody knows what they are, including some of the people responsible for making them happen.

The Oregon Business Association honored 11 Oregonians this year for their contributions to CCOs, which are just being formed after winning legislative approval in 2011. One of the honorees said the task of CCOs is to fill in the white spaces between existing parts of the health care delivery system.

Senator Alan Bates, D-Ashland, talked about filling in the white spaces to ensure greater coordination in delivering health care services to improve patient outcomes and save money. He gave an example of a man who underwent extensive medical treatment for physical ailments, while his underlying psychological issues weren't diagnosed or addressed.

CCOs call for unprecedented levels of coordination between health care providers that are competitors. People seem to be playing well in the sandbox together now, but how it ultimately works out remains unknown.

Just as important is whether CCOs can help stem the tide of rising medical costs for low-income Oregonians as budget pressures build at the state and federal levels to find cuts in Medicaid and Medicare.

The predecessor term to CCOs — accountable care organizations — was first used in 2006 by Elliott Fisher, Director of the Center for Health Policy Research at Dartmouth Medical School, during a discussion at a public meeting of the Medicare Payment Advisory Commission. The term quickly gained credibility, reaching its pinnacle in 2009 when it was included in the federal Patient Protection and Affordable Care Act.  

What Does Health Care Ruling Mean to Oregon?

There are probably as many interpretations as there are analysts looking at the words that Chief Justice John Roberts wrote for the Supreme Court in a historic 5-4 decision upholding major provisions of the Affordable Care Act.

It is tempting to delay comment because so much of what this landmark ruling means will play out over time, both in Washington, D.C. and around the country in states such as Oregon, where Governor John Kitzhaber has taken the lead in implementing reform measures.

Still, here are a few perceptions:

         *  Regardless of how the Court ruled, Oregon was committed to proceed with a number of reforms that emerged from the last two Oregon legislative sessions. That includes the governor's proposal to create Coordinated Care Organizations (CCOs) as mostly non-profit entities to handle the task of organizing and delivering Medicaid services to low-income Oregonians.

         From the governor's standpoint, the new CCOs — eight of which were approved this week to begin operating August 1 and a number of others are in the queue for a later start — will manage Medicaid closer to where people live, prompt providers to collaborate with each other for the benefit of patients and place a great emphasis on prevention, all (at least in theory) to save money.

         If money gets tighter and the CCO reforms don't work, the tough decisions — cutting recipients off Medicaid, cutting back on benefits or cutting provider reimbursements — will fall into the laps of regional or local CCO directors. In the past, these decisions would have been made on the Capitol Mall.

         *  The ruling does retain momentum toward the day, in late 2013 or early 2014, when Oregonians will have a chance to choose health insurance coverage through an online shopping center called an "insurance exchange."  Oregon already is a long way down the road toward starting its exchange and, arguably, would have continued regardless of how the court ruled. But the endorsement of an individual health insurance purchase mandate means the exchange will have a greater chance to succeed a year or so from now. With a few exceptions, those who now don't buy insurance will have to do so.