With one exception, most physician groups stating a position viewed the bill as dangerous.
This article first appeared September 21, 2017 on Medpage Today.
By Shannon Firth
WASHINGTON -- As momentum builds for the GOP's latest Obamacare repeal effort, most major physician and hospital groups skewered the proposal.
But some held their tongues or even welcomed certain new "freedoms" the bill could afford.
Last week senators Lindsey Graham (R-S.C.), Bill Cassidy (R-La.), Dean Heller (R-Nev.), and Ron Johnson (R-Wis.) introduced a healthcare bill to pool money that would have been funnelled into premium and cost-sharing subsidies and Medicaid expansion and direct it instead to states in the form of block grants.
The proposal would also repeal the Affordable Care Act's individual and employer mandates, the medical device tax, and "strengthen the ability for states to waive Obamacare regulations," according to a Sept. 13 press release posted on Cassidy's website. It appears the bill will have no committee hearings or markups before coming to the Senate floor for a vote.
With one exception, most physician groups stating a position viewed the bill as dangerous.
Physicians: 'Do No Harm'
The new bill "violates the precept of 'first do no harm,'" said James Madara, MD, CEO and executive vice president of the American Medical Association, in a letter to Senate Majority Leader Mitch McConnell (R-Ky,) and Minority Leader Chuck Schumer (D-N.Y.).
"Similar to proposals that were considered in the Senate in July, 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," he wrote.
The AMA is especially concerned about repealing the premium subsidies, cost-sharing reductions, small business tax credits, and Medicaid expansion, and described the Medicaid block grants, which would run through 2026 as "inadequate and temporary."
"Per-capita caps (a form of block grant) fail to take into account unanticipated costs of new medical innovations or the fiscal impact of public health epidemics, such as the crisis of opioid abuse currently ravaging our nation," he wrote.
Rebecca Parker, MD, president of the American College of Emergency Physicians, also penned a letter to Senate leadership highlighting the dangers her members see in the bill.
"ACEP cannot support any legislation that does not include emergency medical care as a covered benefit in health insurance," she wrote. "Yet, [the Cassidy-Graham bill] allows states to easily forego requiring insurers to adhere to important consumer protections, including the requirement to cover the ten essential health benefits, and protections for those with pre-existing conditions."
Ninety-five percent of Americans believe health plans should cover emergency medical care, Parker noted, which is currently one of the ACA's essential benefits.
"[E]mergency physicians agree with them. Patients can't choose when and where they will need emergency care, and they shouldn't be punished financially for having emergencies," she continued.
And a joint letter from six specialty organizations representing more than 500,000 physicians -- the American Academy of Family Physicians, the American Academy of Pediatrics, the American Congress of Obstetricians and Gynecologists, the American Osteopathic Association, the American College of Physicians, and the American Psychiatric Association -- described the bill as "disruptive" and "harmful" to patients.
In addition to failing to preserve the coverage and consumer protections enacted by the ACA, the groups said the new bill "would create a health care system built on state-by-state variability that would exacerbate inequities in coverage and most likely place millions of vulnerable individuals at risk of losing their health care coverage."
The groups continued to urge Congress to pursue "regular order" including hearings, debates, and committee markups and not to rush a vote.
Hospitals Disappointed
Because the new bill's approach is similar to previous repeal proposal's, Bruce Siegel, MD, MPH, the president and CEO of America's Essential Hospitals, said he anticipates a similar result: "millions of Americans losing coverage. "
"Unlike those previous proposals, the Graham-Cassidy bill provides no meaningful relief from looming cuts to Medicaid disproportionate share hospital (DSH) payments," he noted, while stressing that the new bill would also limit "how states raise support for the safety net."
"Rather than providing flexibility, this would limit states' coverage and financing choices," he said.
Similarly, "This proposal would erode key protections for patients and consumers and does nothing to stabilize the insurance market now or in the long term," said Rick Pollack, CEO of the American Hospital Association, in a press statement.
On Board, On the Fence
Not all physicans want to see the bill shredded.
Despite her "mixed feelings," Jane Orient, MD, executive director of the Association of American Physicians and Surgeons, said on the whole, "I think that it may in the long-term make things a tiny bit better by permitting a wedge of freedom."
Examples of this freedom include giving block grants to states and rolling back federal regulation so that states can experiment and make their Medicaid programs more efficient.
"The idea that we can just infinitely expand the money that we're pouring into Medicaid is going to come to a halt. It has to. How can you keep spending money that you don't have?" Orient asked.
Half of all Medicaid funding is money coming from creditors, because the government has to borrow 50 cents of every dollar it spends, she said.
The American Association of Neurological Surgeons/Congress of Neurological Surgeons indicated that members like giving states more control over how healthcare dollars are spent, and repeal of the medical device tax. But the group is concerned about "backsliding" on other insurance reforms, such as those involving pre-existing conditions, a press representative told MedPage Today in a phone call.
"Without a [Congressional Budget Office] score, it's impossible to predict what the states are going to do at this point," the representative said. No CBO analysis of the bill other than its effect on the federal budget is expected.
Other specialty groups have remained silent on the bill.
Insurers Skeptical
Another important set of stakeholders also stated opposition to Graham-Cassidy: the health insurance industry, whose chief trade group declared it "cannot support this proposal."
Marilyn Tavenner, CEO of America's Health Insurance Plans, outlined six "guiding principles" in a letter to McConnell and Schumer on Wednesday. They included: stabilizing the individual insurance market, a strong Medicaid program, guaranteed coverage for all, sufficient lead time to implement reforms smoothly, improved affordability, and reliance on the private market.
"The Graham-Cassidy-Heller-Johnson proposal fails to meet these guiding principles," the letter said, "and 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."
Senate leadership aims to bring the bill to the floor for a vote next week. The body faces a Sept. 30 deadline to pass legislation with budgetary implications without needing 60 votes to overcome a filibuster.