How The Budget Deal Affects The Affordable Care Act
So how does this mammoth budget-cutting deal, with its congressional “supercommittee” affect health reform?
Good question, because lots of people in Washington are asking it too.
More specific answers will become clearer in the next few weeks, but here’s a first version of the road map to both the policy and the politics.
First, understand there are two different processes – and each, separately, aims at cutting more than $1 trillion over the next decade.
The one that you’ve probably heard most about is the “supercommittee” of 12 members of Congress. They are supposed to identify savings by Thanksgiving. Entitlements – Medicare, Medicaid, Social Security and aspects of the Affordable Care Act – are part of their turf. So are taxes and revenue – at least in theory. It’s not so clear that the Republicans see it that way given the public statements of Congressional leaders.
If they agree on some kind of grand deal by Thanksgiving, Congress has to take it or leave it by the end of December, eliminating the usual congressional dilly-dallying. (It looks like dilly-dallying to the casual observer or much of the public, but remember that all that arcane, tedious process IS policy in Congress. If you slow something down, make it go through hoops, amend it, hold it up, etc., it doesn’t become law. That may be good or, depending on your point of view, bad politics.)
If Congress takes any recommendations that the supercommittee agrees on, that’s the law. If the committee fails, or Congress rejects it, then the “trigger” gets pulled. The official name is “sequestration.” That’s a fancy name for automatic cuts – 2 percent across-the-board cuts in Medicare, for instance, affecting all health care providers, doctors, hospitals, etc. It won’t affect beneficiaries – at least not directly.
Medicaid is not subject to the trigger. Neither, according to the preliminary interpretations I’ve received from analysts and congressional staff, are the big, key subsidies in the health care reform law – the Medicaid expansion and the subsidies that will help low-income and middle-income people afford health care in the new state exchanges.
Other parts of the health reform law are, however, subject to automatic cuts. Among them: Cost-sharing subsidies for low-income people. This isn’t the help paying the premium; this is the help with the co-pays when people do get care. But the payments are made to health plans, not directly to beneficiaries so it won’t have the direct impact of discouraging care. It may affect how health plans make decisions about what markets to participate in. Gary Claxton and Larry Levitt at Kaiser Family Foundation explain here.
Also, the supercommittee could have a partial deal – meaning there’s still a trigger, but a smaller one. Maybe they won’t reach agreement on $1.2 trillion to $1.5 trillion in savings, which would avoid the trigger. But maybe they could agree on, say, $500 billion. That means a trigger wouldn’t have to go as deep because some of the savings would already be identified.
To recap – before we go on to the second stage of this process: The “super-committee” can do whatever it wants to health care, Medicare, Medicaid, Social Security, etc. – if it can agree, if it can get the rest of Congress to agree and if the president doesn’t veto it.
Will the Democratic Senate and the Obama White House agree to cuts that eviscerate health reform? Not likely. In fact, the Democrats “won” on very few aspects of the budget/debt deal. Walling off Medicaid and key parts of the health coverage expansion were two of the “wins.” That’s a bright line worth paying attention to as this moves forward.
Does that mean other health-reform related spending will be untouched? Given how many moving parts there are to any spending deal, and the fact that defense and tax policy are also part of the mix, chances are it will be affected. But expect to see that bright line remain visible – maybe not quite as bright, but visible. (The CLASS Act, the voluntary long-term care program created under health reform, is a different story; it’s quite vulnerable.)
The second part is the annual appropriations process. The budget deal provides for cuts – real cuts in spending, not just slowing the rate of growth. Health programs (aspects of the health reform legislation touching on exchange creation, prevention, community clinics, etc., and just about everything else at the Department of Health and Human Services – the FDA, NIH, CDC, etc. – will be subject to these cuts. But this isn’t an across the board process, it’s a line-by-line, or at least category/agency-by-category/agency, process. And there is some horse trading.
It’s safe to say that the Republicans will try to cut discretionary portions of the new health law. That’s not a new political dynamic, it doesn’t arise out of the debt ceiling or the Wall Street woes. It’s what we’ve seen since last fall’s elections and the repeal/defund fights of the past few months. And House Budget Chairman Paul Ryan has publicly tried to insert health care into any potential deal. So expect to see more Republican push to cut, and continued Democratic push back. Will health spending emerge unscathed? It’s too soon to know but, given the amount of savings Congress needs to find –both in this budget deal and in the perennial quest to fund the “doc fix” payments – some cuts are clearly possible. Some of it may affect aspects of exchange establishment, regulation, prevention, public health, etc. But it’s hard to see the Democrats allowing cuts so deep that they basically constitute a side door to repeal.
One further twist – some Republicans are calling for a delay in health reform implementation to save money.”Delay” may sound better to an ambivalent public worried about spending than “repeal.” What’s delayed (if anything), how it’s delayed, how long it’s delayed, and what stopgaps are created in the meantime could have an impact on how many people get covered in 2014.
Assorted committees and government agencies are still examining the new budget law and how it will affect … everything. So the perspective I’ve outlined here – and I’m writing amid all the market turbulence – may change as the economic and political climates change. But the lines in the sand around the trigger – health reform, Medicaid and Social Security – tell us something about where the White House will come down.
By: Joanne Kenen, Association of Health Care Journalists, August 10, 2011
A Public Awakening: Wisconsinites Should Be Proud Of What They Accomplished
The history of the American labor movement is crowded with losing battles and crushing disappointments. The men and women who have fought for workers’ rights, often against tremendously long odds, have all too often suffered defeat and humiliation, only finding consolation in the idea that their efforts perhaps succeed in awakening a bit of public sympathy for their plight, inching their larger cause forward in unseen ways.
Yesterday unions and Democrats fell just short of victory in Wisconsin, winning two of six races to recall GOP state senators, in a battle that had unexpectedly emerged as ground zero in a national class war, partly over the fate of organized labor. There’s no way to sugar-coat it: Unions and Dems failed in their objective as they defined it, which was to take back the state senate, put the brakes on Scott Walker’s agenda, and let the nation know that elected officials daring to roll back public employee bargaining rights would face dire electoral consequences.
But nonetheless, what they failed to accomplish does not diminish what they did successfully accomplish. The fact that all these recall elections happened at all was itself a genuine achievement. The sudden explosion of demonstrations in opposition to Walker’s proposals, followed by activists pulling off the collection of many thousands of recall signatures in record time, represented an undiluted organizing triumph. At a time of nonstop media doting over the Tea Party, it was a reminder that spontaneous grassroots eruptions of sympathy and support for a targeted constituency are still possible and can still be channeled effectively into a genuine populist movement on the left. At a time when organized labor is struggling badly and GOP governors earn national media adulation by talking “tough” about cracking down on greedy public employees, what happened in Wisconsin, as John Nichols put it, amounted to “one of the largest pro-labor demonstrations in American history,” one that carried echoes of the “era of Populist and Progressive reform in the late nineteenth and early twentieth centuries.”
What’s more, no matter how many times conservatives falsely assert that labor and Dems subverted the popular will by fighting Walker’s proposals, in reality precisely the opposite happened.
By staging a fight that drew national attention, labor and Wisconisn Dems revealed an unexpected level of national sympathy for public employees, and, yes, for unions and their basic right to exist. This alone was an important achievement, flummoxing pundits who had confidently predicted that public employeees would make easy public scapegoats for the national conservative movement in dire economic times.
Even if Dems fell short of their objective in Wisconsin, what happened was, in fact, a referendum on Walkerism — one that conservatives lost in the mind of the broader public. Nate Silver Tweeted last night: “Dems would be silly to not proceed with the Walker recall based on tonight. The results project to a toss-up if you extrapolate out statewide.” I don’t think Dems will go through with it, but Silver’s larger point is intact: Walkerism triggered a strong public backlash that can’t be dismissed and will remain a factor. As Markos Moulitsas noted, the Wisconsin battle enabled Dems to hone a class-based message about GOP overreach that is showing some success in winning back white working class voters, with potential ramifications for 2012. The national outpouring of financial support for the Dem recall candidates showed that there’s a national liberal/Dem constituency that can be activated by Dems who don’t flinch from taking the fight to opponents with unabashedly bare-knuckled populism.
Will the national support for public employees in polls slow the drive of conservatives and GOP governors to roll back bargaining rights nationally? Probably not. Conservatives will point to yesterday’s events, with some justification, as proof that governors might not suffer direct electoral consequences in response to radical union-busting policies. But what Wisconsin showed us is that the broader public simply isn’t on their side. Let’s hope national Dems take heart.
The events in Wisconsin were a blow to organized labor. But the simple fact is that labor and Dems came within a hair of realizing an objective that was dismissed at the outset of this fight as a delusional lefty pipe dream. Wisconsin won’t chasten the left; Wisconsin will embolden it. And those who poured untold amounts of time and energy into the Wisconsin effort shouldn’t regret their efforts for a second.
By: Greg Sargent, The Plum Line-The Washington Post, August 10, 2011
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