Rescissions Package Shows Washington’s Spending Problem

Talk about swampy: Republicans control the House, the Senate, and the White House, yet even token attempts to reduce spending cannot succeed.

Last week’s failure of a $15 billion package of rescissions (i.e., spending cuts) that the administration had proposed partly reflected the narrow Republican majority in the Senate. With Republicans’ one-vote margin, objections by Sens. Susan Collins (R-ME) and Richard Burr (R-NC) sank the measure in a 48-50 vote.

Health Care: Dems Demagogue, GOP Caves

Nearly half of the proposed savings, approximately $7 billion, in the rescissions package came from the State Children’s Health Insurance Program (SCHIP)—roughly $5.1 billion in unobligated balances, and $1.9 billion in child enrollment contingency funds for the current fiscal year that ends in September.

Liberals claimed the rescissions package would “gut” the contingency fund and “put the health of children at risk.” However, the Congressional Budget Office (CBO) last month noted that, with respect to the $5.1 billion in unobligated SCHIP balances, “authority to distribute the funds to states…expired in 2017.”

CBO also “projected that the rescission from the child enrollment contingency fund would not affect payments to states.” In sum, the budget office concluded that the $7 billion rescission “would not affect…the number of individuals with insurance coverage.”

Had Republicans stuck to their prior principles on SCHIP, much of the rescissions package would have proved unnecessary. Congress never would have authorized the funds in the first place, eliminating the need to rescind that spending. They did not. Collins voted against the package because of the SCHIP funds, while Sen. Lisa Murkowski (R-AK) voted to support it, but very begrudgingly.

Parochial Interests Clip the Other Vote

The other Senate Republican no vote came from Burr, a surprise opponent of the measure. Burr said he opposed the package’s $16 million reduction in funding for the Land and Water Conservation Fund.

Burr’s staff told the Washington Post they had not received assurances that Burr could receive a vote on an amendment striking the land and water reduction from the package, leading the senator to oppose the procedural motion to bring the package to the floor.

On the other hand, killing a $15 billion spending reduction package over literally 0.1 percent of its contents seems more than slightly absurd. With the federal debt at $21 trillion and rising, if Congress will not act on this package—buckets of unspent money lying around at agencies, like spare change under the proverbial couch cushions—when will it discover fiscal discipline?

All Dessert, No Spinach

The defeat of this rescissions package means another may not follow in short order. The administration wanted to propose reductions in spending from March’s omnibus legislation. But appropriators like Senate Majority Leader Mitch McConnell (R-KY) said that one party clawing back money included in a bipartisan budget deal might impede Congress’ ability to pass budget-busting legislation in the future. (Quelle horreur!)

The administration relented in the short-term, hoping to start a virtuous cycle of fiscal responsibility and set spending-reducing precedent they could build upon. Unfortunately, however, the administration failed to recognize the magnitude of this Congress’ bipartisan addiction to federal spending.

Sooner or later, Congress will end up passing spending reductions of a much larger scale than last week’s rescissions package. That they failed to start that task when they had an easy opportunity—the lowest of the low-hanging fruit—will make the spending reductions Congress ultimately enacts that much larger, and more painful.

This post was originally published at The Federalist.

Summary of Health Care “Consensus” Group Plan

Tuesday, a group of analysts including those at the Heritage Foundation released their outline for a way to pass health-care-related legislation in Congress. Readers can find the actual health plan here; a summary and analysis follow below.

What Does the Health Plan Include?

The plan includes parameters for a state-based block grant that would combine funds from Obamacare’s insurance subsidies and its Medicaid expansion into one pot of money. The plan would funnel the block grant funds through the State Children’s Health Insurance Program (SCHIP), using that program’s pro-life protections. In general, states using the block grant would:

  • Spend at least half of the funds subsidizing private health coverage;
  • Spend at least half of the funds subsidizing low-income individuals (which can overlap with the first pot of funds);
  • Spend an unspecified percentage of their funds subsidizing high-risk patients with high health costs;
  • Allow anyone who qualifies for SCHIP or Medicaid to take the value of their benefits and use those funds to subsidize private coverage; and
  • Not face federal requirements regarding 1) essential health benefits; 2) the single risk pool; 3) medical loss ratios; and 4) the 3:1 age ratio (i.e., insurers can charge older customers only three times as much as younger customers).

Is That It?

Pretty much. For instance, the plan remains silent on whether to support an Obamacare “stability” (read: bailout) bill intended to 1) keep insurance markets intact during the transition to the block grant, and 2) attract the votes of moderate Republicans like Alaska Sen. Lisa Murkowski and Maine Sen. Susan Collins.

As recently as three weeks ago, former Sen. Rick Santorum was telling groups that the proposal would include the Collins “stability” language. However, as I previously noted, doing so would likely lead to taxpayer funding of abortion coverage, because there are few if any ways to attach pro-life protections to Obamacare’s cost-sharing reduction payments to insurers under the special budget reconciliation procedures the Senate would use to consider “repeal-and-replace” legislation.

What Parts of Obamacare Would the Plan Retain?

In short, most of them.

Taxes and Medicare Reductions: By retaining all of Obamacare’s spending, the plan would retain all of Obamacare’s tax increases—either that, or it would increase the deficit. Likewise, the plan says nothing about undoing Obamacare’s Medicare reductions. By retaining Obamacare’s spending levels, the plan would maintain the gimmick of double-counting, whereby the law’s payment reductions are used both to “save Medicare” and fund Obamacare.

Insurance Regulations: The Congressional Research Service lists 22 separate new federal requirements imposed on health insurance plans under Obamacare. The plan would retain at least 14 of them:

  1. Guaranteed issue of coverage—Section 2702 of the Public Health Service Act;
  2. Non-discrimination based on health status—Section 2705 of the Public Health Service Act;
  3. Extension of dependent coverage—Section 2714 of the Public Health Service Act;
  4. Prohibition of discrimination based on salary—Section 2716 of the Public Health Service Act (only applies to employer plans);
  5. Waiting period limitation—Section 2708 of the Public Health Service Act (only applies to employer plans);
  6. Guaranteed renewability—Section 2703 of the Public Health Service Act;
  7. Prohibition on rescissions—Section 2712 of the Public Health Service Act;
  8. Rate review—Section 2794 of the Public Health Service Act;
  9. Coverage of preventive health services without cost sharing—Section 2713 of the Public Health Service Act;
  10. Coverage of pre-existing health conditions—Section 2703 of the Public Health Service Act;
  11. Summary of benefits and coverage—Section 2715 of the Public Health Service Act;
  12. Appeals process—Section 2719 of the Public Health Service Act;
  13. Patient protections—Section 2719A of the Public Health Service Act; and
  14. Non-discrimination regarding clinical trial participation—Section 2709 of the Public Health Service Act.

Are Parts of the Health Plan Unclear?

Yes. For instance, the plan says that “Obamacare requirements on essential health benefits” would not apply in states receiving block grant funds. However, Section 1302 of Obamacare—which codified the essential health benefits requirement—also included two other requirements, one capping annual cost-sharing (Section 1302(c)) and another imposing minimum actuarial value requirements (Section 1302(d)).

Additionally, the plan on two occasions says that “insurers could offer discounts to people who are continuously covered.” House Republicans offered a similar proposal in their American Health Care Act last year, one that imposed penalties on individuals failing to maintain continuous coverage.

However, the plan includes no specific proposal on how insurers could go about offering such discounts, as the plan states that the 3:1 age rating requirement—and presumably only that requirement—would not apply for states receiving block grant funds. It is unclear whether or how insurers would have the flexibility under the plan to offer discounts for continuous coverage if all of Obamacare’s restrictions on premium rating, save that for age, remain.

This post was originally published at The Federalist.

Biden Precedent Provides Roadmap for Repealing Obamacare with 51 Votes

With Congress having effectively repealed its individual mandate in the tax relief bill, what should Republicans do about Obamacare now?

While eliminating a penalty for Americans who cannot afford government-approved health insurance removes a financial burden on low-income families, it does not give people the freedom to purchase the coverage they do want to buy. Doubtless the president’s October executive order, when implemented, will provide more affordable options through regulatory relief. But ensuring that relief remains intact through future administrations will require legislative action.

How Joe Biden Used His Senate Presidency

While Democrats did not use budget reconciliation—a Senate procedure allowing bills to pass with a simple 51-vote majority, instead of the 60 votes needed to overcome a filibuster—to pass Obamacare, they did use a reconciliation bill to “fix” the law they passed. In March 2010, the Senate considered, and President Obama eventually signed, a reconciliation bill that removed the odious “Cornhusker Kickback” for Nebraska, and made other amendments to the health law.

That reconciliation bill also changed Obamacare’s regulatory regime. Specifically, Section 2301(a) of the reconciliation measure applied four insurance requirements—limiting waiting periods to join employer plans, banning lifetime limits, ending rescissions by insurers, and extending coverage to “dependents” under age 26—to “grandfathered” health plans established before the law’s enactment. In addition, Section 2301(b) of the bill amended Obamacare itself, removing language that limited under-26 “dependent” coverage to unmarried individuals.

During consideration of the reconciliation bill on the Senate floor, Iowa Republican Chuck Grassley objected to including these provisions. He argued that Section 2301 of the bill violated the Senate’s “Byrd rule,” designed to prevent the inclusion of matters with a merely incidental fiscal component on a budget reconciliation bill. In a colloquy memorialized in the Congressional Record, Vice President Biden, acting in his capacity as president of the Senate, overruled Grassley, and said the provisions in question did in fact comply with the “Byrd rule.”

“Grandfathered” plans do not qualify for Obamacare subsidies, and many do not qualify for any tax preference. Yet Biden held that the new requirements on “grandfathered” plans held enough of a fiscal nexus to comply with the “Byrd rule” for budget reconciliation. As a result, the “Biden precedent” allows the Senate to enact—or to repeal outright—health insurance rules through the reconciliation process.

Democrats Paved the Way for Obamacare Repeal

Moreover, the particular insurance requirements included in Section 2301(a)—especially the restrictions on employer waiting periods and the ban on rescissions—carry a relatively small fiscal impact. Because Vice President Biden ruled that Democrats could enact these comparatively small requirements in a reconciliation bill, Senate Republicans should have every right to repeal more costly restrictions, such as those on essential health benefits and actuarial value, outright through budget reconciliation, rather than relying upon the cumbersome state waiver processes included in last year’s bills.

Senate sources indicate that, recognizing the “Biden precedent” would allow for a robust Obamacare repeal, Democratic staffers tried to limit its impact last year. They argued to Elizabeth MacDonough, the Senate parliamentarian, that changes covered by that precedent were targeted in scope, technical in nature, and limited only to plans that qualify for subsidies.

But a textual analysis of the 2010 reconciliation bill shows that it changed requirements for all types of health insurance, not just “grandfathered” plans, and not just those that qualified for subsidies. And because Biden overruled Republican objections that these changes to insurance rules exceeded the scope of budget reconciliation in 2010, Republicans can and should use that precedent to undo Obamacare’s regulatory regime.

Obamacare’s insurance rules represent the beating heart of the law, necessitating a massive system of subsidies and tax increases to make this newly expensive coverage “affordable.” Because Democrats used the “Biden precedent” to impose some of those rules through budget reconciliation, Republicans have every opportunity to repeal these requirements outright through a reconciliation bill. They should take that opportunity, for removing the regulatory regime would effectively repeal Obamacare—and permanently restore health care freedom to the American people.

This post was originally published at The Federalist.

Democrats’ Priorities: Corporate Welfare or Zika?

If Nero was the emperor who fiddled while Rome burned, Barack Obama must surely qualify as the president who dithered while his signature initiative rapidly crumbled. Despite a public-health emergency in sections of the southern United States, the president seems more interested in shoveling money to insurers than in stopping the threat from the Zika virus.

Last week the New York Times reported that the Obama administration was attempting yet another Obamacare relaunch, this one including a federally funded “advertising campaign featuring newly insured individuals, as well as direct appeals to young people hit by tax penalties this year for failing to enroll.” With enrollment in the law’s exchanges well below original estimates, insurers leaving in droves, and premiums ready to spike, the move seems to be a desperate attempt to increase sign-ups and keep insurers at the Obamacare table.

But the timing of the announcement could not be more incongruous. Even as the Department of Health and Human Services wastes taxpayer dollars to promote yet again a measure enacted into law six years ago — on which public opinion has remained decidedly stable (and negative) — HHS also claims that it desperately needs additional funding to fight the Zika virus. Senate Majority Leader Mitch McConnell wrote to HHS on Friday to ask why the agency’s leaders  believe that taxpayer dollars “would be better spent propping up the failed Obamacare exchanges than other important public health priorities — such as preventing the spread of Zika.”

The fact remains, however, that HHS’s top priority is propping up the failed Obamacare experiment — a bigger priority than obeying the text of Obamacare itself. The non-partisan Congressional Research Service and other outside experts have concluded that, in implementing Obamacare’s reinsurance program, the administration violated the law by prioritizing payments to insurers over payments to the Treasury. As a result, insurers will receive billions of dollars in extra funding that legally should be returned to taxpayers.

To sum up the situation: The Obama administration is funneling billions of dollars to “greedy” insurers that Democrats hate, while Nancy Pelosi and other Democrats have called for Congress to return from its recess to pass billions of dollars in spending to fight Zika. There is, however, an easy win-win solution: Use the reinsurance funds to pay for the new Zika spending, rather than giving insurance companies another Obamacare bailout.

The Zika conference report that the House passed in June did pay for new spending on the virus by rescinding some unspent Obamacare funds. Two-thirds of the funds rescinded, however ($543 million in total), came from an account used to establish Obamacare exchanges in United States territories. With exchanges having been established for years, this “rescission” amounts to Congress agreeing not to spend money that was never going to be spent anyway — a “pay for” on paper rather than in reality.

By contrast, utilizing reinsurance funds to finance Zika spending would represent a legitimate savings to taxpayers. Such a move would reclaim billions of dollars that otherwise would have been (unlawfully) diverted to insurance companies — some of which would fund the new Zika spending, and some of which would be returned to the taxpayers to whom the funds belonged in the first place.
Using reinsurance dollars to fund a Zika package would be not only good policy but good politics as well. Most Americans would put the health of infants and pregnant women over the health of insurance companies’ bottom lines — and so should Congress. If Democrats wish to defend crony capitalism and corporate-welfare payments to insurers, that is their right. But particularly after the premium spikes hit this fall, few may wish to do so.

As the old saying goes, to govern is to choose. Senator McConnell rightly pointed out last week that this administration has prioritized its failed Obamacare experiment over protecting Americans from the Zika virus. When it comes to finding any new source to pay for new Zika spending, ending Obamacare’s reinsurance bailout should stand at the top of the priority list.

This post was originally published at National Review.

Fact Check: “At the Mercy of Insurance Companies”

The Hill reports that, during his remarks to AARP this morning, the President attacked Republicans for leaving seniors “at the mercy of insurance companies.”  Well, in case you missed it, here are five ways the President and his Administration have left seniors at the mercy of one organization with insurance interests – AARP – by granting them special exemptions and ignoring their questionable insurance practices:

  1. AARP’s lucrative Medigap insurance was exempted in Obamacare from the ban on pre-existing conditions; medical loss ratio requirements; caps on insurance industry executive compensation; and the tax on all other health insurance plans.
  2. The Department of Health and Human Services didn’t think all these Obamacare exemptions were enough; last year they also exempted Medigap insurance from premium rate review – even though AARP, which carries the plan with the largest market share, earns greater profits the more seniors pay in premiums.
  3. At a conference hosted by America’s Health Insurance Plans in March 2010, HHS Secretary Sebelius encouraged the insurance industry to give up some of its profits, at a time when health insurance profit margins were about 2 percentYet neither Secretary Sebelius nor anyone else in the Administration ever criticized AARP for making a profit margin of nearly 5 percent on its Medigap insurance.
  4. In April 2010, the Administration engaged in very public efforts to “encourage” insurance companies to ban rescissions and extend coverage to young adults earlier than is required by the law.  But no one from the Administration has taken similar steps to encourage AARP to stop discriminating against sick seniors applying for Medigap coverage.
  5. In a speech at an AARP conference in October 2010, Secretary Sebelius praised AARP as the “gold standard in cutting through spin and complexity to give people the accurate information they need.”  Yet the National Association of Insurance Commissioners (NAIC) has previously expressed concern about the potential for conflicts-of-interest associated with percentage-based compensation arrangements.  So Secretary Sebelius praised as the “gold standard” for “accurate information” an organization that has the types of financial conflicts her insurance commissioner colleagues have criticized as ripe for abuse.

If the President is so worried about leaving seniors at the mercy of insurance companies, perhaps he should tell the people within his own Administration to stop granting political favors to Democrats’ cronies at the AARP.

The Obama Administration’s Protection Racket

Shortly, President Obama will be addressing the AARP convention via satellite.  He will undoubtedly say nice things about AARP’s role as a “senior advocate.”  But what he won’t discuss are the ways in which his own Administration has allowed AARP to continue making billions in profits on its insurance business:

  1. AARP’s lucrative Medigap insurance was exempted in Obamacare from the ban on pre-existing conditions; medical loss ratio requirements; caps on insurance industry executive compensation; and the tax on all other health insurance plans.
  2. The Department of Health and Human Services didn’t think all these Obamacare exemptions were enough; last year they also exempted Medigap insurance from premium rate review – even though AARP, which carries the plan with the largest market share, earns greater profits the more seniors pay in premiums.
  3. At a conference hosted by America’s Health Insurance Plans in March 2010, HHS Secretary Sebelius encouraged the insurance industry to give up some of its profits, at a time when health insurance profit margins were about 2 percentYet neither Secretary Sebelius nor anyone else in the Administration ever criticized AARP for making a profit margin of nearly 5 percent on its Medigap insurance.
  4. In April 2010, the Administration engaged in very public efforts to “encourage” insurance companies to ban rescissions and extend coverage to young adults earlier than is required by the law.  But no one from the Administration has taken similar steps to encourage AARP to stop discriminating against sick seniors applying for Medigap coverage.
  5. In a speech at an AARP conference in October 2010, Secretary Sebelius praised AARP as the “gold standard in cutting through spin and complexity to give people the accurate information they need.”  Yet the National Association of Insurance Commissioners (NAIC) has previously expressed concern about the potential for conflicts-of-interest associated with percentage-based compensation arrangements.  So Secretary Sebelius praised as the “gold standard” for “accurate information” an organization that has the types of financial conflicts her insurance commissioner colleagues have criticized as ripe for abuse.

Why might the Administration look the other way despite these abuses?  Documents released by the Energy and Commerce Committee yesterday provide myriad reasons, showing all the political favors senior Administration officials asked of AARP as they rammed Obamacare through Congress:

  • Jim Messina, White House Deputy Chief of Staff: “We need [AARP CEO] Barry Rand to go meet with Ben Nelson personally and just lay it on the line.  ‘We will be with you, we will protect you.  But if you kill this bill, seniors will not forget.’  We are at 59 [votes in the Senate], we have to have him.” (page 7)
  • Jim Messina: “Can we get immediate robo calls into Nebraska urging [Ben] Nelson to vote for cloture?” (page 9)
  • Nancy-Ann DeParle, Director, White House Office of Health Reform: “Can AARP support accountable care orgs [sic] and some other delivery system reforms?” (page 26)
  • Jim Messina: “Latest top 25 targets list from House leadership” (page 35)
  • Ann Widger, Office of Public Engagement: “We would really like AARP to participate in this roundtable.” (page 37)
  • Ann Widger: “Did you guys put out any paper today on the McCain [Medicare] amendment?” (page 39)
  • Jim Messina: “[Rep. Larry] Kissel a problem…Help.” (pages 42-43)
  • Nancy-Ann DeParle: “Can you get me a copy of the [AARP] bulletin we discussed yesterday?” (page 64)

Secretary Sebelius has already admitted she has acted improperly in using her office to conduct political activities; the Office of Special Counsel last week concluded she violated the law to do so.  Given all of the above, it is not unreasonable to question whether the Secretary, and others within the Administration, made a calculated political decision to grant special favors to AARP – and ignore its questionable business practices – because AARP endorsed Obamacare.

Yesterday President Obama claimed that he changed Washington “from the outside” by enacting Obamacare.  The pattern of conduct described above suggests just the opposite: That the President rammed Obamacare through only by establishing what amounts to an inside-the-Beltway protection racket between the Administration and AARP – the former will allow the latter to continue overcharging seniors for insurance, so long as AARP uses its advocacy megaphone to endorse the President’s liberal causes.

 

The Honorable Kathleen Sebelius

Secretary

Department of Health and Human Services

200 Independence Avenue, S.W.

Washington, DC 20201

Dear Secretary Sebelius:

Today my office is releasing a report, “Profits Before Principles,” regarding the insurance practices of AARP. The report finds that AARP has a strong financial interest in keeping Medigap supplemental insurance premiums high – because the organization receives greater profits the more seniors pay in premiums. In addition, AARP’s financial interests have been aided by the Patient Protection and Affordable Care Act (PPACA), which AARP not coincidentally endorsed. Experts agree that PPACA’s provisions will have the effect of driving seniors out of Medicare Advantage health plans and into Medigap supplemental insurance – a market where AARP enjoys the largest market share.

I am greatly concerned by AARP’s questionable business practices, and by the numerous exemptions granted to Medigap insurance – both legislatively and through your Department’s regulatory process – as a result of PPACA. Therefore, I ask you to respond to the following questions:

  1. The text of PPACA exempts Medigap supplemental insurance plans from several new requirements: Section 1103 exempts plans from medical-loss ratio requirements; Section 1202(2)(A) exempts plans from the prohibition on pre-existing condition exclusions; Section 9014 exempts plans from caps on industry executive compensation; and Section 10905(d) exempts plans from the tax applied to all other health insurers. Does the Administration support all these special exemptions for Medigap plans? Why or why not?
  2. My staff attended a PPACA implementation briefing for Senate Republican staff in April 2010. At that time, Jeanne Lambrew of your Department’s Office of Health Reform admitted that PPACA exempted Medigap insurance from the law’s new regulatory regime. If in fact the Administration does NOT support PPACA’s numerous exemptions for Medigap plans, why has your Department done nothing to publicize that fact in the intervening two-plus years since that briefing?
  3. Your Department continues to claim that PPACA “ended many of the insurance industry’s worst abuses” – even though you are fully aware that these changes do not apply to Medigap plans. For instance, HHS previously released a publicity brochure that says “starting in 2014, discrimination based on a pre-existing condition by an insurer will be prohibited in every state.” Why has your Department continued to repeat these misleading slogans, even though your staff admitted that seniors applying for Medigap insurance remain subject to pre-existing condition discrimination due to the special carve-outs included in PPACA?
  4. In your speech to the Democratic National Convention on September 4, 2012, you criticized Republicans for “let[ting] insurance companies continue to cherry-pick who gets coverage and who gets left out, priced out, or locked out of the market.” Likewise, during his speech at the Democratic National Convention, President Obama said that “no American should have to spend their golden years at the mercy of insurance companies.” Please detail the specific provisions included in PPACA that place new limits on Medigap insurers’ ability to “cherry-pick who gets coverage and who gets left out, priced out, or locked out of the market,” and ensure that no applicant for Medigap coverage with a pre-existing condition will be left “at the mercy of insurance companies.”
  5. In a speech on September 8, 2012, President Obama claimed that Medicare premium support proposals would lead to billions of dollars in greater profits for insurance companies. But a 2011 House Ways and Means Committee member report found that PPACA itself could lead to billions in profits for AARP, because the law’s cuts to Medicare Advantage will reduce enrollment in that program, and encourage seniors to purchase supplemental Medigap insurance instead. Do you agree with the Ways and Means Committee report’s premise that PPACA will lead seniors to migrate from Medicare Advantage coverage to Medigap plans – thereby increasing profits to AARP? If not, on what basis do you disagree with the non-partisan experts at the Congressional Budget Office and the Medicare Office of the Actuary, who have concluded the law will reduce Medicare Advantage enrollment by millions?
  6. In addition to the above exemptions, your Department added yet another Medigap carve-out to the ones included in the statute, by exempting Medigap insurance from PPACA’s rate review process. Why do seniors not deserve this supposed protection? If PPACA’s benefits are so good, why didn’t your Department extend them to seniors as well?
  7. Did AARP, or anyone associated with or paid by it, influence or attempt to influence the Administration regarding the numerous exemptions given to Medigap insurance in PPACA, or the regulatory interpretations of PPACA? If so, please provide details as to the dates, persons, positions, and circumstances of said efforts.
  8. The 2011 House Ways and Means Committee member report noted that for its Medigap plans, AARP receives 4.95% of every premium dollar paid by seniors. As a former insurance commissioner, do you think it’s appropriate that AARP has a perverse financial incentive to keep Medigap insurance premiums high?
  9. In a speech at an AARP conference in October 2010, you praised that organization as the “gold standard in cutting through spin and complexity to give people the accurate information they need.” As a former insurance commissioner, how exactly do you believe AARP can serve as a “gold standard” giving seniors “accurate information” about Medigap insurance plans, when the organization has a financial incentive to sell seniors more insurance than they may need or want?
  10. As a former insurance commissioner, you are no doubt aware that the National Association of Insurance Commissioners (NAIC) has previously expressed concern about the potential for conflicts-of-interest associated with percentage-based compensation arrangements. In fact, Section 18 of NAIC’s Producer Model Licensing Act recommends that states require explicit disclosure by insurer affiliates, and clear written acknowledgement by consumers, of any percentage-based compensation arrangement, due to the potential for financial abuses. Did you undertake any due diligence to ensure that AARP’s Medigap percentage-based compensation model was in full compliance with both the letter and spirit of Section 18 of the Producer Model Licensing Act prior to making your assertion that AARP constitutes the “gold standard” for giving seniors “accurate information?” If not, why not?
  11. Given that AARP holds the largest share of the Medigap market, why did your Department grant a special exemption for Medigap insurance from PPACA rate review? Why do you believe that AARP can act in a proper manner to control premium increases – even though the organization gains profits for every additional dollar Medigap premiums rise?
  12. At a conference hosted by America’s Health Insurance Plans in March 2010, you encouraged the insurance industry to give up some of its profits, at a time when health insurers were earning between 2 and 3 cents of profit for every dollar of revenue, according to Fortune 500 estimates. If you criticized other insurers for earning between 2 and 3 cents of every premium dollar in profits, why haven’t you criticized AARP for taking 4.95 cents of every Medigap premium dollar as pure profit?
  13. In April 2010, the Administration and you personally engaged in very public efforts to “encourage” insurance companies to ban rescissions and extend coverage to young adults earlier than was required by PPACA. Why haven’t you taken similar steps to encourage AARP to stop discriminating against sick seniors applying for Medigap coverage?
  14. At the April 2010 Senate Republican briefing, staff asked whether your Department would write a letter to AARP asking them to stop denying Medigap applications for individuals with pre-existing conditions. Jeanne Lambrew of the Office of Health Reform promised to look into the matter, but the letter was never sent. Why has your Department waited more than two and a half years to ask AARP to stop discriminating against sick and disabled individuals applying for Medigap insurance?
  15. Finally, please forward copies of any and all Administration documents – including those originating from outside your Department – from January 20, 2009 through today inclusive regarding: 1) the Medigap exemptions included in PPACA, and the Administration’s viewpoints and/or technical assistance provided regarding same during the drafting process; 2) the Administration’s administrative interpretations of the Medigap exemptions during the rulemaking process; 3) AARP’s positions on Medigap insurance plans, including but not limited to the exemptions included in PPACA; and 4) AARP’s position on PPACA, including but not limited to any policy changes AARP said it required to be included in the legislation for the bill to receive the organization’s endorsement.

I look forward to receiving your response on these issues within two weeks. If you have any questions, feel free to contact Alec Aramanda or Chris Jacobs of my staff. Thank you for your time, and I look forward to your reply.

Health Provisions in Labor-HHS Appropriations Measure

As you are probably aware, the House introduced an omnibus appropriations bill early this morning; the Labor-HHS division of the bill can be found here.  A few policy points worth highlighting:

  • The bill includes a ban on HHS funding of needle exchange programs; according to the House Appropriations Committee, this provision had been included in the bill prior to Fiscal Year 2010.
  • The bill also includes a blanket ban on HHS funds being used “in whole or in part, to advocate or promote gun control.”  According to the House Appropriations Committee, this ban had previously been confined solely to Centers for Disease Control funds.
  • The bill rescinds $400 million from the co-operative grant program included in Section 1322 of Obamacare.  As you may recall, $2.2 billion of the original $6 billion in funding was rescinded in the six-month continuing resolution (P.L. 112-10).  This additional rescission means $3.4 billion in co-operative funding would remain available.
  • The bill rescinds $10 million of the $15 million in mandatory funding for the Independent Payment Advisory Board provided in Section 3403 of Obamacare.
  • The bill rescinds approximately $6.4 billion in performance bonuses created in the 2009 SCHIP reauthorization (P.L. 111-3).
  • The bill requires the Secretary to establish “a publicly accessible website to provide information” regarding funds spent in the Prevention and Public Health Fund created by Section 4002 of Obamacare.  Grants over $25,000 would have to be publicly identified within 5 days of award, and recipients would have to provide semi-annual reports on their activities.  Some Members have previously expressed concern first that this fund would be used to fund questionable projects like jungle gyms and bike paths, and second that this fund suffers from accountability problems due to the mandatory, auto-pilot nature of the spending.  The President’s September deficit submission proposed reducing spending on the Fund by $3.5 billion over ten years.
  • The bill also  contains several prohibitions on grant funding from the Prevention and Public Health Fund from being used “for publicity or propaganda purposes,” or to fund the salaries of lobbyists.  This section also includes a prohibition on Prevention Fund monies being used to promote tax increases or “the advocacy or promotion of gun control.”

A full summary featuring several top-line spending numbers for the Labor-HHS bill can be found on the appropriations website here.  One particular note of caution if you’re trying to analyze the bill itself:  The last section of the bill includes an across-the-board rescission of 0.189 percent, so the actual spending levels under the bill would be lower than the bill’s plain text.

Health Provisions in Six-Month Continuing Resolution

As you will be aware, the House Appropriations Committee filed the six-month continuing resolution (through September 30) early this morning.  Text is available here, and a list of discretionary program reductions outlined by the Appropriations Committee is available here. (The Rules Committee also posted the text of two separate enrolling resolutions related to health care; summaries of those provisions will be sent under separate cover.)  House floor action is expected as soon as tomorrow, with the Senate expected to follow thereafter.

Unfortunately, CBO scoring estimates, including “runs” providing budget authority figures, are not yet available (other than the list of program reductions provided by the Appropriations Committee, and linked to above).  Below is a summary of the health care policy-related changes included in the CR.

Provisions related to the Department of Health and Human Services can be found on pages 311-324 and 337-342 of the text posted online.  (As usual, Food and Drug Administration funding is included in the Agriculture Department appropriations title, pages 191-95, and Indian Health Service funding is included in the Interior appropriations title, page 300.)  However, a BIG caveat for those reading through the CR text itself: Section 1119 provides for a 0.2 percent across-the-board rescission of budget authority for ALL discretionary appropriations, applying to “each discretionary account” and “each program, project, and activity.”  In other words, the discretionary account figures included in the text of the Labor-HHS title do NOT represent the final budgetary authority given – so don’t forget to read the bill with that in mind.

We will have more information on both policy and process as it becomes available.

 

Prevention “Slush Fund”:  Section 1855 requires that all money transferred from the Prevention and Public Health Fund established in the Patient Protection and Affordable Care Act (PPACA) to discretionary accounts (e.g., Centers for Disease Control, HRSA, etc.) comply with Section 503 of Division D of P.L. 111-117, which prohibits funds from being used “for publicity or propaganda purposes.”

GAO and Related Audits:  Section 1856 calls for several audits related to provisions included in PPACA:

  • A GAO report listing contracts, outside firms, and consultants used to implement new authorities provided by PPACA, due within 90 days of enactment;
  • A GAO report auditing “requests for administrative waiver of the annual limit requirements” under PPACA, including “an analysis of the number of approvals and denials of such requests and the reasons for such approval or denial,” due within 60 days of enactment;
  • A report by the Medicare actuary, due within 90 days of enactment, containing “an estimate of the impact of the guaranteed issue, guaranteed renewal, and community rating requirements…on premiums for individuals and families with employer-sponsored health insurance.  Such estimate shall cover the 10-year period beginning with 2014 and shall include an estimate of the number of such individuals and families who will experience a premium increase as a result of such requirements and the number of such individuals and families who will experience a premium decrease as a result of such requirements.”
  • A GAO report “that includes the results of an audit of expenditures made for comparative effectiveness research funds” in the “stimulus” or PPACA, due within 60 days of enactment.

Co-Op Rescission:  Section 1857 rescinds $2.2 billion of the $6 billion in start-up funding provided for the Consumer Operated and Oriented Plan (Co-Op) program created under Section 1322 of PPACA.

Free Choice Program:  Section 1858 repeals Section 10108 of PPACA, which provided for “free choice” vouchers for workers whose employer-provided health insurance premiums cost between 8 percent and 9.8 percent of family income.

Performance Bonuses:  Section 1859 rescinds $3.5 billion in performance bonus payments authorized in the 2009 SCHIP reauthorization (P.L. 111-3).  The program provides for bonuses for states that increase their Medicaid enrollment above threshold levels while engaging in at least five enrollment and retention provisions specified in the statute.  In 2009, the Congressional Budget Office scored the performance bonus provisions as costing $4.4 billion over the 2009-2019 budget window in its estimate of the SCHIP legislation as enacted.

Update on Continuing Resolution and the Week Ahead

As you are likely aware, Congress late Friday evening cleared and the President signed a short-term “bridge” continuing resolution funding the federal government through April 14 (i.e., midnight Thursday).  That bill, which can be found online here, contained $2 billion in additional spending cuts, none of which came from the Department of Health and Human Services.

With respect to a longer-term CR through September 30, that language is still being drafted; press reports indicate that the bill text could be made public (likely on the House Rules Committee website here) later today.

Various press reports and a dispatch from the Speaker’s Office have indicated that as part of the budget agreement, the Senate will proceed to votes on stand-alone measures repealing/defunding Obamacare and a measure related to Planned Parenthood/Title X family planning funding.  Text and timing of any such votes remain unclear. (As a reminder, the Senate is NOT in session today; the body will reconvene at 10 AM tomorrow, with a judicial confirmation vote scheduled at noon, ahead of the policy lunches.)

Finally, White House advisor David Plouffe indicated on the Sunday shows yesterday that the President will finally be laying out his entitlement “reform” agenda in a speech on Wednesday.  It is unclear what exactly the President will propose – other than to re-state his commitment to raise taxes on small businesses that create American jobs.  This morning’s Politico notes that “there aren’t a lot of Democratic ideas” with respect to reforming Medicare and Medicaid (as opposed to the House Republican budget, which will be debated in that chamber at the end of the week).

Floor Update on 1099 and Repeal Votes

In case you hadn’t seen it, on this round of Senate votes just concluded:

  • The Levin amendment (1099 repeal paid for by tax increases on oil and gas companies) failed on a 44-54 vote;
  • The Stabenow amendment (1099 repeal paid for by rescission of discretionary appropriations) passed, following an 81-17 vote to waive a Budget Act point of order;
  • The McConnell amendment on repeal failed on a party-line 47-51 vote to waive a Budget Act point of order.