Trumpcare Passage, Medicaid Changes in Sight

While the nation stood transfixed by former FBI director James Comey’s testimony before the Senate, that same body moved closer to putting forth a Trumpcare bill—potentially signaling major changes to the way home health companies receive Medicaid payments.

The under-the-radar movement was enough to prompt one Washington insider, speaking before a health care conference in Chicago on Sunday, to predict that the Senate has a better than 50-50 chance of passing an Obamacare repeal by July 4.

That’s a stark contrast from the general mood in Washington after the House narrowly passed its American Health Care Act (AHCA) back in May, when senators on both sides of the aisle expressed concern about some of its provisions and vowed to cautiously develop a bill of their own.

Faced with President Trump’s low approval numbers and daily media coverage of the administration’s scandals, Senate Republicans are under even greater pressure to deliver a win for the party and the White House, National Association for Home Care & Hospice Vice President for Law Bill Dombi said at the Post Acute Link Care Continuum Conference. He placed the odds of a bill making it out of the Senate by the Independence Day recess at “better than even.”

“It’s, politically, so important to do so,” Dombi said, noting a very real fear among Republicans that the party could lose control of the House and Senate in the 2018 midterms amid growing voter dissatisfaction with the president—and lose their chance to pass Trump and House Speaker Paul Ryan’s signature Obamacare-repeal legislation along with it.

“They don’t have the luxury of waiting for the next cycle,” added Mark Kalish, CEO of the S4 Group, a Skokie, Ill.-based lobbying firm.

Thanks to Comey’s attention-grabbing testimony, senators have been able to focus on hammering out a palatable version of a bill away from the glare of the media and constituent anger.

“The best thing that could have happened for the Trump administration for the AHCA was the Comey testimony,” said panelist Jeanette Badrov, the associate director of Medicaid and Medicare policy at the University of Illinois at Chicago.

Dombi said he had recently met with a team of aides to Sen. Susan Collins, a Maine Republican who was initially critical of some of the AHCA’s provisions. But now, Dombi said, the aides had resigned themselves to being on the losing side, citing the defections of key GOP skeptics of the AHCA such as Sen. Bill Cassidy of Louisiana and Sen. Dean Heller of Nevada.

“Sen. Collins is sitting out there almost alone, and they could lose Sen. Collins and still pass it,” Dombi said.

Much of the discussion at Sunday’s event focused on the impact of the AHCA’s per-capita Medicaid cap, a major overhaul of the way the federal government would fund the program—the largest payer for skilled nursing services.

Under that system, states would receive a set amount for each Medicaid recipient, with the exact dollar figure varying by the type of person receiving care. For example, Americans older than 62 would receive a certain amount, with all future increases pegged to historic state Medicaid funding from fiscal year 2016.

That could present a problem for states—such as Illinois—that run “lean” Medicaid operations, according to Badrov. Since the per-capita cap would permanently base the dollars allotted for each recipient on 2016 figures, states that implemented Medicaid cuts or generally offered fewer services that year could be put at a permanent disadvantage compared to bigger-spending states such as New York.

But no matter what a state’s Medicaid history, per-capita caps will impel governors and legislatures to find cuts elsewhere, Badrov said.

“The states are now going to be forced to come up with more money from somewhere else,” she said, adding that other public services such as education could face funding pressure. “That’s going to have a domino effect on all the other providers in the state.”

Dombi cautioned that no one has actually read any substantive text of the Senate’s plan, though he indicated that the upper chamber’s bill will likely provide more protections for those with preexisting conditions, increase funding for subsidies offered to the uninsured, and address the so-called “age tax” — AARP’s term for premium increases for older Americans under the AHCA.

All three of those issues caused alarm after the passage of the House bill, which the nonpartisan Congressional Budget Office said would result in 23 million Americans losing health coverage. The bill would also reduce Medicaid funding by $800 billion over the next decade.

The panelists emphasized that Obamacare repeal wouldn’t necessarily spell doom for industries that rely on Medicare and Medicaid payments: For instance, Dombi called SNF coverage “a solid benefit” that states would be reluctant to cut, while home care companies could see a surge as states scramble to save money. But he urged executives in the skilled nursing and home health industries to step up their lawmaker advocacy in the coming months and years, while also taking preemptive steps to cope with the long-term effects.

“We won’t see a tidal wave of problems if we go to per-capita caps immediately,” Dombi said. “It’s going to take time. We have time to prepare.”

And he added a cautionary note about the general unpredictability in Washington, especially given the Trump administration’s shaky start and growing extracurricular distractions.

“If anyone expects me to explain what’s been going on in Washington in a logical fashion, then you must not be watching television,” Dombi said.

Written by Alex Spanko

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