September 22, 2017 Edition

Butte County Awarded Accreditation Status

We are delighted to announce that Butte County’s Department of Public Health Department was awarded national public health accreditation status by the Public Health Accreditation Board (PHAB) earlier this week.  Butte becomes the tenth local health department awarded PHAB recognition in California along with CDPH.

Please join us in congratulating the hard work and success of our colleagues in Butte. Further information on PHAB and the press release can be found here.

Graham-Cassidy Proposal Unexpectedly Gains Momentum, Floor Vote Next Week Uncertain

Seeing the proposal as a last-minute opportunity to repeal and replace the Affordable Care Act (ACA) prior to the expiration of key procedural powers at the end of the month, Senate Republicans have been quickly attempting to gather votes on H.R. 1628 by Senators Lindsey Graham (R-South Carolina) and Bill Cassidy (R-Louisiana) and cosponsored by Senators Dean Heller (R-Nevada) and Ron Johnson (R-Wisconsin).

However, Senator John McCain (R-Arizona) announced this morning that he will not be voting in support of the legislation. McCain joins Senator Rand Paul (R-Kentucky) in opposition, likely sinking the Republicans’ current attempt at repealing the ACA. Senators Susan Collins (R-Maine) and Lisa Murkowski (R-Alaska) have yet to publicly announce their support of or opposition to the proposal; during the last attempt to repeal the ACA, Collins and Murkowski voted against the proposal.

The Graham-Cassidy legislation would use $1.2 trillion in funds spent under the ACA’s tax credits, Medicaid expansion, and cost-sharing payments to instead provide states with large block grants. States could use federal funds largely as they see fit and apply for waivers, and major components of the ACA would be overhauled or completely eliminated under the measure. For example:

  • Medicaid funding for states would switch from an open-ended basis to a capped per-capita basis
  • Medicaid expansion would be eliminated and funds would be reallocated to states
  • Essential health benefits, including maternity care, prescription drug coverage, and mental health services, would vary as states would be permitted to apply for waivers as to what qualifies as an essential health benefit. This would also impact coverage of pre-existing conditions and threaten prohibitions on annual and lifetime limits of insurance coverage.
  • Individual and employer mandates for health coverage would be eliminated
  • Cost-sharing reduction payments to insurers to cover medical costs for lower-income patients would be eliminated
  • Tax credits for low-to-middle income Americans to defray cost of insurance premiums would be eliminated

The Congressional Budget Office (CBO) has indicated it does not have enough time to produce a full analysis of the potential impact of the Graham-Cassidy proposal before its vote next week. However, the CBO is aiming to provide a preliminary assessment of the proposal by early next week.

A myriad of other organizations, such as the Kaiser Family Foundation and the Center on Budget and Policy Priorities, have analyzed the proposal and have projected dire impacts on funding, health services, and the rate of uninsured Americans. The Medicaid per-capita cap alone is projected to cut federal funding that supports seniors, people with disabilities, families and children, and pregnant women by an estimated $175 billion over ten years and more than $1 trillion over 20 years.

A significant redistribution of federal funds across states would occur through the implementation of block grants with Medicaid expansion states losing over $180 billion for ACA coverage and non-expansion states gaining over $73 billion over a six year period. California alone has been projected to lose federal funds in upwards of $78 billion over the same six year period under the Graham-Cassidy proposal. To make matters worse, the Prevention and Public Health Fund (PPHF) would be stripped of its funding in 2019, severely impacting the services delivered by local health departments.

The number of individuals and groups opposed to the Graham-Cassidy proposal continue to grow significantly. Late this week, the National Association of Medicaid Directors (NAMD), representing all state Medicaid directors, issued a strong statement warning of the massive burden the proposed legislation would have on states. Citing per-capita caps and block grant funding, NAMD declared the Graham-Cassidy proposal “would constitute the largest intergovernmental transfer of financial risk from the federal government to the states in our country’s history.”

Organizations such as the Blue Cross-Blue Shield Association (BCBSA), the American Medical Association (AMA), the American Association of Retired Persons (AARP), and an increasing group of bipartisan governors have also come out in strong opposition to the proposed legislation. CHEAC joined our fellow California county organization colleagues in a recent opposition letter to the Graham-Cassidy proposal over concerns with capping Medicaid federal funding and the impact on the uninsured rate.

In addition to McCain and Paul announcing their intention to vote against the legislation, the clock is ticking for Senate Republicans to pass the Graham-Cassidy proposal as key procedural powers that permit the passage of measures with only a simple majority expire on September 30. Typically, major legislation requires 60 votes to gain passage in the Senate.

Bipartisan efforts to stabilize the health insurance marketplace and fix the ACA between Senators Lamar Alexander (R-Tennessee) and Patty Murray (D-Washington), chair and vice chair of the Senate Health, Education, Labor, and Pensions (HELP) Committee, respectively, were shelved earlier this week as Republicans instead took up pursuit of the Graham-Cassidy proposal.

A hearing is set for H.R. 1628 on Monday in the Senate Finance Committee, though it remains to be seen if Senate Republicans will still hold a floor vote on the Graham-Cassidy proposal to make good on their seven-year long promise to repeal the ACA once and for all.

DHCS Releases Analysis of Graham-Cassidy Proposal

The California Department of Health Care Services (DHCS), in collaboration with Covered California and the Department of Finance (DOF), released a preliminary analysis on the potential impact the Graham-Cassidy proposal would have on California. The analysis notes similar programmatic and fiscal concerns with previous Republican health care proposals, but notes the Graham-Cassidy proposal “is the most devastating of the three federal health care proposals” that DHCS has evaluated this year.

The DHCS analysis projects a massive cost shift from the federal government to states, resulting in nearly $4.4 billion in additional costs to California in 2020 and growing to $22.5 billion in 2026. The cumulative impact to California between 2020 and 2027 is expected to be $138.8 billion in federal funding cuts. DHCS highlights its most significant concerns with the Graham-Cassidy proposal, which include:

  • Shift in Medicaid federal financing to per-capita limit
  • Elimination of federal funding for Medicaid expansion
  • Time-limited state block grant program
  • Elimination of enhanced funding for IHSS

DHCS indicates the Graham-Cassidy proposal would result in a massive fiscal burden placed on the state, impacting not only the Medi-Cal program, but the larger health care delivery system on which all Californians rely. Should the Graham-Cassidy proposal become law, California will be faced with tens of billions of dollars in new costs and forced to make critical decisions regarding the populations and benefits covered.  The DHCS analysis overview is available here and the 2020-2027 analysis is available here.

Newsom Indicates Support for Universal, Single-Payer Coverage

Appearing before the California Nurses Association, Lieutenant Governor Gavin Newsom today urged state legislators to move forward with SB 562 by Senator Ricardo Lara which would establish universal, single-payer health care in California. Recall, the measure was shelved in the Assembly by Speaker Anthony Rendon earlier this summer, due to a lack of details around funding, delivery, and cost controls.

Newsom did not explicitly endorse SB 562 in its current form, but indicated his strong support for the concept of universal, single-payer coverage. If he is elected governor next year, Newsom vowed a “firm and absolute commitment” to pass universal health care.

With the newly formed Assembly Select Committee on Health Care Delivery Systems and Universal Coverage, it remains to be seen what action the Legislature will take, when legislators return to Sacramento next year.

Climate Action Team Public Health Workgroup to Meet in October

The California Climate Action Team Public Health Workgroup Quarterly Meeting (CATPHWG) will be held on Tuesday, October 17, 2017 from 1:00 pm to 3:30 pm at the CalEPA Sierra Hearing Room, Second Floor (1001 I Street, Sacramento, CA). For those unable to attend in person, the meeting will also be available via webcast. The meeting will focus on tree health, human health, and climate change.

For questions, please contact Dan Woo with the California Department of Public Health (CDPH) at