July 14, 2017 Edition
Upon returning from their Independence Day Recess this week, Senate Republicans unveiled their revised version of the ‘Better Care Reconciliation Act’ to repeal-and-replace the Affordable Care Act. Senate Republicans experienced intense turmoil from within their party and stiff opposition from the general public after releasing their initial discussion draft of the BCRA on June 22. The most recent version of the bill slightly reworks several provisions related to coverage requirements and payment options, tax breaks, and opioid epidemic funding.
What has changed from the initial BCRA draft?
“The Cruz Amendment” – An amendment ushered by Senator Ted Cruz would permit insurers to offer lower cost, slimmed-down coverage as long as insurers offer at least one plan that meets current ACA standards. Under current law, insurers are required to meet minimum essential benefit coverage requirements.
Funding for Out-of-Pocket Costs – The first BCRA draft included $112 billion for states to reduce premiums and out-of-pocket costs. The revised version of the BCRA increases federal funding by $70 billion bringing the total to $182 billion.
Health Savings Accounts for Premiums – The updated BCRA version would permit individuals to use health savings accounts to pay for their health insurance premiums in excess of any tax benefit they already receive to purchase health care.
Catastrophic Coverage – The revised BCRA would allow anyone to purchase a catastrophic health plan and permit people otherwise eligible for federal subsidies to receive tax credits to purchase catastrophic health plans. Under the ACA, only young adults and certain other people are eligible to purchase catastrophic plans with low premiums, and federal subsidies are not available for these plans.
Opioid Funding – In an attempt to address the growing national opioid epidemic, the revised bill provides $45 billion to states for substance abuse treatment and recovery services. The previous version of the BCRA allocated $2 billion for one year.
Funding for Certain States – In a further attempt to sweeten the deal for some Republican Senators, the revised BCRA includes additional federal funding for certain states. Alaska, for example, would receive $1.3 billion in funding to keep its insurance markets stable.
Tax Breaks – The previous version of the BCRA included a series of tax breaks benefiting the wealthy and high-earning health insurance executives. In the revised version, BCRA would keep some of the ACA taxes used to fund the law’s coverage expansion and eliminate two tax cuts benefiting the wealthy. Most taxes under ACA, however, would be repealed.
What remains the same in the revised BCRA?
Medicaid Overhaul – The revised BCRA still includes deep cuts to Medicaid to the tune of nearly $800 billion, most notably through phasing out state Medicaid expansion under the ACA from 2020 through 2024. The slowed growth rate of federal spending for Medicaid still remains in the reworked BCRA.
Individual Mandate – ACA penalties for going without health insurance would be eliminated and individuals who have not been continuously covered would be locked out of the health insurance marketplace for six months.
Tax Credit Reductions – Senate Republicans retained provisions making coverage tax credits available to individuals earning up to 350 percent of the federal poverty level. The ACA currently provides tax credits to individuals earning up to 400 percent of the federal poverty level.
Coverage for Older Adults – Maintained in the revised BCRA are provisions permitting insurers to charge older enrollees up to five times as much as their younger enrollees. Under current law, insurers can only charge up to three times as much for older enrollees.
Cost-Sharing Subsidies – Payments to insurers to cover most low-income individuals in ACA marketplaces would be extended for two years before being eliminated, a provision that remains unchanged in the revised BCRA.
Planned Parenthood Funding – The revised BCRA still eliminates federal funding for Planned Parenthood for one year and prohibits individuals from using Medicaid services at Planned Parenthood clinics.
What is next?
Despite reworking provisions of the BCRA, Senate Republican Leader Mitch McConnell faces a difficult road ahead. A score from the Congressional Budget Office (CBO) is expected on Monday, but the score is not expected to include the Cruz Amendment. A handful of moderate Senate Republicans remain leery of the revised version of the bill, citing the drastic overhaul of Medicaid, not enough funding to address the opioid crisis, and the restriction of funding of Planned Parenthood services. To attempt to secure the support of these moderate Senate Republicans, additional sweeteners have been included in the revised measure, including $1.3 billion in federal funding to Alaska. Vice President Mike Pence has also been enlisted by Majority Leader McConnell to assist by meeting personally with both moderate senators and state governors.
Majority Leader McConnell is eyeing to begin debate on the revised BCRA next week and hold a vote shortly thereafter. However, Republicans appear to be simply focused on pulling together enough votes for a procedural motion to begin debate. With two Republicans on record already opposing the procedural motion, McConnell cannot afford for another senator to vote against the procedural motion; doing so would kill the Republican’s attempt to repeal the ACA altogether. Some Republican Senators have suggested their path forward may require them to scrap the BCRA and work with Senate Democrats to craft a new health care measure.
Today is the deadline for policy committees to meet and report fiscal bills, resulting in a busy week of hearings. Policy committees have one more week to meet and report all remaining bills before the Legislature departs for its summer recess.
Below are several bills of interest to CHEAC Members. This week’s full bill chart is available here.
Local Health Department Administration
AB 1250 (Jones-Sawyer) as amended 6/21/17 – Oppose
AB 1250 by Assembly Member Reginald Jones-Sawyer was heard in the Senate Governance and Finance Committee this week. The measure would place onerous requirements on county contracting, including many of the contracts into which local health departments enter for vital public health services.
The hearing featured nearly an hour of robust testimony and questions from committee members around potential restrictions and impacts to county operations. Despite the extensive debate, the measure was advanced to the Senate Rules and Senate Appropriations Committees by a 4-2 vote with Committee Chair, Mike McGuire not voting on the bill. Further amendments that may exempt certain services and entities or rural areas are expected over the coming weeks. CHEAC, along with CSAC and hundreds of other organizations, remain opposed to AB 1250.
AB 725 (Levine) as introduced 2/15/17 – Support
Assembly Member Marc Levine’s AB 725 was heard this week in the Senate Appropriations Committee. The measure would ban smoking (including e-cigarettes) and disposal of cigar and cigarette waste at all state coastal beaches, state parks and campgrounds, monument and landmark sites, and sites of historical interest. AB 725 was placed on the Senate Appropriations Suspense File.
AB 175 (Chau) as amended 5/30/17 – Support
AB 175 by Assembly Member Ed Chau was heard in the Senate Health Committee this week. The measure would require adult use cannabis manufacturers, prior to releasing cannabis-infused edible products, to receive approval from CDPH, including submitting their packaging and labeling to the Department. The measure was advanced to the Senate Appropriations Committee.
SB 663 (Nielsen) as amended 7/12/17 – Support
Senator Jim Nielsen’s SB 663 was heard in the Assembly Business and Professions Committee this week. The measure would deem packaging or labeling of cannabis products as appealing to children if: 1) it including transparent packaging, 2) the product displays a name that resembles the name of any existing non-cannabis candy, snack food, baked good, or beverage, 3) the product contains a design feature that resembles the packaging or labeling of a non-cannabis candy, snack food, baked good or beverage, 4) the product includes any statement, artwork, or design that is misleading to a person under 21, 5) if it includes any cartoon, logo, or design feature making it primarily attractive to children, and 5) if it includes a name or slogan appealing primarily to those under 21. The measure was advanced to the Assembly Floor.
AB 210 (Santiago) as amended 7/3/17 – Support
Assembly Member Miguel Santiago’s AB 210 was heard in the Senate Judiciary Committee this week. This measure is sponsored by Los Angeles County and would allow counties to establish multidisciplinary teams to facilitate the expedited identification, assessment, and linkage of homeless individuals to housing and supportive services. AB 210 was advanced to the Senate Appropriations Committee.
SB 138 (McGuire) as amended 6/29/17 – Support
The CHEAC Legislative Committee moved to support SB 138 by Senator Mike McGuire this week. The measure would require local education agencies participating in the federal school meal program to implement a system to directly certify students eligible for free or reduced price meals using Medi-Cal participation data. The measure would also require school districts and county offices of education with high poverty schools to provide breakfast and lunch free of charge to all students at those schools. The measure was advanced from the Assembly Education Committee to the Assembly Appropriations Committee.
Drug & Alcohol Services
AB 1048 (Arambula) as amended 7/3/17 – Watch
Assembly Member Joaquin Arambula’s AB 1048 was heard in the Senate Health Committee this week. The measure would authorize a pharmacist to dispense a Schedule II drug as a partial fill if requested by the patient or prescribing physician. The measure would also remove the requirement on health facilities to assess the pain of a patient at the same time as their vital signs are taken. This measure has been introduced to attempt to address the growing opioid epidemic in California. AB 1048 was advanced to the Senate Appropriations Committee.
Access to Health Services
AB 1591 (Berman) as amended 3/28/17 – Support
AB 1591, authored by Assembly Member Marc Berman, was heard in the Senate Appropriations Committee this week. The measure would expand Medi-Cal reimbursement eligibility to include Licensed Professional Clinical Counselors (LPCCs) in federally qualified health centers (FQHCs) and rural health centers (RHCs). The measure was placed on the Senate Appropriations Suspense File.
This week, the California Legislative Analyst’s Office (LAO) released its annual California Spending Plan to summarize the annual state budget that was just passed by the Legislature and signed into law by Governor Brown. This publication is the first preliminary report of the 2017-2018 budget; the LAO will release an updated version of the publication, which will reflect actions taken later in the legislative session in the fall. The report includes key features of the 2017-2018 Budget Package, as well as spending details by program area. To view the full LAO report, visit here.
The California Department of Public Health (CDPH) will be hosting two upcoming webinars to provide information to local health departments on the Proposition 56 Oral Health Program funding opportunity. The webinar will be hosted by the California Dental Director Dr. Jayanth Kumar and CDPH colleagues. Two webinar sessions will be offered:
July 26, 2017 from 10:30 am-12:00 pm
July 27 from 2:00 pm-3:30 pm
Attendees are encouraged to select the date and time that works best for you; both webinars will feature the same information. To register for the webinar, please visit here. Attendee materials are available here. For additional information and questions, please contact the CDPH Oral Health Program at DentalDirector@cdph.ca.gov.
This week, former CDC Director Dr. Tom Frieden and former Senate Majority Leader Bill Frist penned an opinion editorial in The Hill detailing potential outcomes of cuts to the budget of the U.S. Centers for Disease Control and Prevention (CDC). Frieden and Frist indicate proposed budgets from the Trump Administration and U.S. Congress stand to endanger American lives, weaken public health capacity, and result in increased illness and disease, among other outcomes. The full editorial article is available here.
This week, the California Department of Public Health (CDPH) Safe and Active Community Branch (SACB) released new epidemiology data on pedestrian injuries in California between 2007 and 2013. The report details the frequency and severity of motor vehicle-involved pedestrian injuries throughout the state using Statewide Integrated Traffic Records System (SWITRS) data. Findings of the report include an 11 percent increase of pedestrian fatality rates and a 13.5 percent decrease of non-fatal pedestrian injury rates between 2007 and 2013. The full CDPH SACB report is available here.
The National Association of Chronic Disease Directors (NACDD) recently released a report entitled Local Health Department and School Partnerships: Working Together to Build Healthier Schools. The report utilizes a “Whole School, Whole Community, Whole Child” collaborative approach to child learning and health and provides case studies and examples of LHD and school partnerships in reducing and preventing chronic disease. The NACDD report is available here.
CHEAC Staff Member Jack Anderson recently had research he conducted presented at the 2017 AcademyHealth Annual Meeting in New Orleans, Louisiana. Anderson’s research explored disease management and community-clinical linkage strategies for patients with chronic disease conditions employed locally by primary care providers across the state of Nebraska. The study found primary care providers in Nebraska, particularly those affiliated with large health systems, are highly active in managing chronic diseases through referrals and linkages. The research poster on which Anderson is listed as an author is available here.