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Fontenotes: Three Things to Watch in 2018

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By Sarah Fontenot

As 2018 peeks over the horizon, it promises to be another year of health care headlines and talking heads, with political free-for-alls, wins, and losses.

Sarah FontenotThere will be many things to keep track of, including (presumably) some issues we don’t even know about yet.

But I promise you there will be at least three things to be watching in the year to come, and I would like to give you a quick preview of each.


Please read on!

1. Will there be an Obamacare Repeal & Replace 2.0?

Politicians do not return to the scene of their most significant defeats, and the Senate is not known for picking up controversies that die on their chamber floor.

That explains why, after the Senate bill to defeat Obamacare failed in July, Senate Majority Leader Mitch McConnell (R-KY) announced “that the Senate will give up on its bill to replace” the Affordable Care Act (ACA) and focus on repeal only “in the next two years.”

After the second defeat in August, McConnell described the future of the effort as “murky” and said that Republicans in the Senate would talk with Democrats to find measures on which the two parties might be able to agree.

A surprising third blitz for repeal and replace under a bill co-sponsored by Sens. Lindsey Graham (R-SC) and Bill Cassidy, MD (R-LA) died without a vote on Sept. 26, and the party moved on to the Tax Bill.

With three strikes out*, many watchers thought 2017 would bring the end to the “Repeal & Replace” fervor. (*More depending on how you count the bills.)

Accordingly, on Dec. 22 McConnell told the Associated Press he was skeptical at best about revisiting Obamacare in the Senate. On the 29th (pointing to the loss by Roy Moore in Alabama that brought the GOP Senate majority to one seat) he reiterated that in 2018 the Senate would “probably move on to other issues.”

But has anyone told Sen. Lindsey Graham?

On Dec. 21, Graham tweeted: "To those who believe — including Senate Republican leadership — that in 2018 there will not be another effort to Repeal and Replace Obamacare — well you are sadly mistaken."

A week later, Graham announced his commitment with Senator Cassidy to renew the push in 2018 for their bill that failed in the fall.

Is the Senate poised to begin “Repeal and Replace 2.0?”

Be watching.

2. Will the Insurance Markets be Stabilized?

In a Fontenotes last April I explained the controversy surrounding subsidies to insurance companies under the ACA in some detail. I returned to the issue in October to highlight the bipartisan effort led by Sens. Lamar Alexander (R-TN) and Patty Murray (D-WA) to save the subsidies after an executive order from President Donald Trump stopped them.

Those same subsidies will be a “hot topic” for Congress moving into 2018. There is significant disagreement among Republicans about continuing to reimburse insurance companies under the ACA formula, particularly in the House of Representatives. As I described in my previous Fontenotes, the result of that debate could significantly raise the cost of insurance on the ACA exchanges, and arguably for the rest of us as well.

But no one will be watching what happens next more closely than Sen. Susan Collins (R-.ME).

You will remember that Senator Collins was a crucial vote for the GOP in 2017; she voted (or announced her intent to vote*) against all three “Repeal and Replace” efforts in the Senate.

(*Her announced intention to vote against Graham-Cassidy was “the final death blow” to the bill that died with a whimper- not an actual vote.)

And then came the Tax Bill in December.

Explaining her vote (again crucial) to pass the tax bill, Senator Collins “told reporters she had an ‘ironclad’ commitment from McConnell and Vice President Mike Pence to pass legislation by the end of the year to stabilize Obamacare premiums.”

But that didn’t happen.

With a now one-vote majority in the Senate, can the GOP leadership afford not to keep that promise to Senator Collins in 2018? And if broken, how will it affect her vote on her other choice health care issues, such as protecting Medicare?

I am confident Senator Collins will be watching to see what happens with the Alexander/Murray compromise to subsidize the insurance markets.

And so should you.

3. Will CHIP be Saved?

The Children’s Health Insurance Program [CHIP] was created in 1997 as a joint federal-state program to provide health insurance to low-income children whose families are not eligible for Medicaid, but are too poor to be able to afford insurance.

It currently offers free or reduced-cost health care to nearly 9 million children, with some states taking the option under the law to cover pregnant women as well.

From its inception, CHIP has enjoyed “unusually strong bipartisan support,” yet this fall its funding fell victim to the other pressures on Congress, and “disagreements between the House and Senate over how to offset funds.” (Congress did not begin to start with the necessary legislation to renew its funding until October, although they have known for two years that funding was set to expire Sept. 30.)

A $3 billion stop-gap measure passed in December was supposed to keep the program alive until March 2018, but that is proving to be not true.

CHIP is an issue that affects all states, but some are running out of money more quickly. In November, Texas requested $90 million from the Centers for Medicare & Medicaid Services to keep its program running through February, and received $135 million in mid-December. Wisconsin (which by state law must continue coverage even if the federal government reneges) announced it would lose $115 million a year if Congress does not act. Pennsylvania only has enough funds to last until February, which will mean “176,000 children are going to be without health insurance.” (Notice all three examples are “Trump States.”)

The Trump Administration and many states are “fervently” searching for additional stopgap measures while waiting for Congress to address the funding issue.

However, with Congress having to return to the budget in January – as well as other “daunting” tasks such as budget caps, DACA, disaster relief, and now sexual harassment procedures – how will CHIP fare?

More to the point: How will CHIP be measured by those (such as Speaker Paul Ryan) who hope 2018 will be the year when entitlement reform is a priority?

Lots of people are worried about the future of CHIP, but only Congress can save it. Will they?

Be watching.

Want to know more?

Keeping track of how DC is changing health care is a full-time job. There are a number of resources I rely on, but none are more valuable to me than “The Health 202,” a Power Post from the Washington Post. It is written by Paige Winfield Cunningham and is exceptional. Here are some end of year examples I think you would enjoy:

I highly recommend you sign up to get Paige’s posts directly. (A “Sign Me Up” button appears at the end of each post I just listed.)

Sarah Fontenot is both a nurse and an attorney. Today, as a professional speaker, she travels the country, helping people understand how health care is changing and what it means for them as consumers. Visit her website.

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