While the GOP-controlled U.S. House of Representatives continues its push to dismantle the Affordable Care Act, the American Medical Association, the American Hospital Association and AARP are all opposed to the GOP’s proposed replacement plan — the “American Health Care Act.” In the following letters sent to the House of Representatives on March 7, they each explain why.

AMA: “We cannot support the AHCA as drafted”

On behalf of the American Medical Association, I am writing to share our views on the proposed “American Health Care Act” (AHCA).

More than 20 million Americans currently have health care coverage due to the Affordable Care Act (ACA) and among the AMA’s highest priorities for on-going health system reform efforts is to ensure that these individuals maintain that coverage. While we agree that there are problems with the ACA that must be addressed, we cannot support the AHCA as drafted because of the expected decline in health insurance coverage and the potential harm it would cause to vulnerable patient populations.

The AMA has long supported advanceable, refundable tax credits as a preferred method for assisting individuals in obtaining private health care coverage. It is important, however, that the amount of credits available to individuals be sufficient to enable one to afford quality coverage. We believe that credits should be inversely related to an individual’s income. This structure provides the greatest chance that those of the least means are able to purchase coverage. We believe credits inversely related to income, rather than age as proposed in the committee’s legislation, not only result in greater numbers of people insured but are a more efficient use of tax-payer resources.

AMA policy also supports increased flexibility in the Medicaid program so that states may pursue innovations that improve coverage for patients with low incomes. We are concerned, however, with the proposed rollback of the Medicaid expansion under the ACA. Medicaid expansion has proven highly successful in providing coverage for lower income individuals. Beyond the expansion, the underlying structure of Medicaid financing ensures that states are able to react to economically driven changes in enrollment and increased health care needs driven by external factors. The Medicaid program, for example, has been critical in helping many states cope with the increased demand for mental health and substance abuse treatment as a result of the ongoing crisis of opioid abuse and addiction. Changes to the program, therefore, that limit the ability of states to respond to changes in demand for services threaten to force states to limit coverage and increase the number of uninsured.

In addition to the concerns listed above, the AMA cannot support provisions that repeal the Prevention and Public Health Fund or that eliminate the ability of patients to receive their care from qualified providers of their choice. The Public Health and Prevention Fund has supported many critical projects, including investments in immunization, childhood lead poisoning, and health-care associated infections. Currently the fund comprises approximately 12 percent of the budget of the Centers for Disease Control and Prevention and should be preserved. In addition, choice of health care provider is an important element of a reformed health care system. The AMA cannot support provisions that prevent Americans from choosing to receive care from physicians and other qualified providers, in this specific case, those associated with Planned Parenthood affiliates, for otherwise covered services.

As you consider this legislation over the coming days and weeks, we hope that you will keep upmost in your mind the potentially life altering impact your decisions will have on millions of Americans who may see their public, individual or even employer-provided health care coverage changed or eliminated. We encourage you to ensure that low and moderate income Americans will be able to secure affordable and adequate coverage and that Medicaid, CHIP, and other safety-net programs are maintained and adequately funded. And critically, we urge you to do all that is possible to ensure that those who are currently covered do not become uninsured.

AHA: “We cannot support the AHCA in its current form”

On behalf of our nearly 5,000 member hospitals, health systems and other health care organizations, and our clinician partners — including more than 270,000 affiliated physicians, 2 million nurses and other caregivers, and the 43,000 health care leaders who belong to our professional membership groups, the American Hospital Association (AHA) is writing to express our views on The American Health Care Act, legislation to repeal and replace the Affordable Care Act (ACA).

As lawmakers work to re-examine this law, patients and the caregivers who serve them across America are depending on Congress to make continued coverage a priority. We believe that any changes to the ACA must be guided by ensuring that we continue to provide health care coverage for the tens of millions of Americans who have benefitted from the law. We are pleased that so many in Congress also recognize the need to preserve patient coverage.

We believe the legislation needs to be reviewed through this lens, and carefully evaluated regarding its impact on both individuals and the ability of hospitals and health systems — which are the backbone of the nation’s health care safety net in terms of our ability to care for all of those who walk through our doors.

Any ability to evaluate The American Health Care Act, however, is severely hampered by the lack of coverage estimates by the Congressional Budget Office (CBO). Lacking that level of analysis and needed transparency, we urge that Congress should wait until an estimate is available before proceeding with formal consideration.

In addition to the lack of a CBO score, we have some additional policy concerns with the proposal.

For example, it appears that the effort to restructure the Medicaid program will have the effect of making significant reductions in a program that provides services to our most vulnerable populations, and already pays providers significantly less than the cost of providing care.

Providing flexibility to the states to expand coverage, and create innovative financing and delivery models to improve care and program sustainability, can be achieved through other alternatives. For instance, the expanded use of waivers — with appropriate safeguards — can be very effective in allowing state flexibility to foster creative approaches and can improve the program more effectively than through imposing per-capita caps.

In addition, the legislation repeals much of the funding currently dedicated to provide coverage in the future. Furthermore, we object to eliminating the funding from some sources, but leaving in reductions to payments for hospitals’ services. If coverage is not maintained at the current level, those resources need to be returned to hospitals and health systems in order to provide services to what will likely be an increased number of uninsured Americans.

At the same time, while we commend the recent actions by the Congress to address behavioral health issues, as well as the drug epidemic that is impacting virtually every community we serve, it is important to recognize that significant progress in these areas is directly related to whether individuals have coverage. And, we have already seen clear evidence of how expanded coverage is helping to address these high-priority needs.

Health care coverage is vitally important to working Americans and their families. They rely on hospitals and health systems to provide them with access for their essential health care needs in a manner that is of the highest quality, not to mention the full range of critical life-saving services, including preventive benefits, that will further improve the quality of their lives and the health of the communities in which they live.

We recognize this measure represents the first step in a process. It is critical that this process be thoughtful and focused on finding ways to improve our health care system, particularly for the poor, elderly and disabled.

We ask Congress to protect our patients, and find ways to maintain coverage for as many Americans as possible. We look forward to continuing to work with the Congress and the Administration on ACA reform, but we cannot support The American Health Care Act in its current form.





AARP: “We write today to express our opposition to the American Health Care Act”

AARP [American Association of Retired Persons], with its nearly 38 million members in all 50 States and the District of Columbia, Puerto Rico, and U.S. Virgin Islands, is a nonpartisan, nonprofit, nationwide organization that helps people turn their goals and dreams 

into real possibilities, strengthens communities and fights for the issues that matter most to consumers and families such as health care, employment and income security, retirement planning, afford-able utilities and protection from financial abuse.

We write today to express our opposition to the American Health Care Act. This bill would weaken Medicare’s fiscal sustainability, dramatically increase health care costs for Americans aged 50-64, and put at risk the health care of millions of children and adults with disabilities, and poor seniors who depend on the Medicaid program for long-term services and supports and other benefits.

Medicare

Our members and older Americans believe that Medicare must be protected and strengthened for today’s seniors and future generations. We strongly oppose any changes to current law that could result in cuts to benefits, increased costs, or reduced coverage for older Americans. According to the 2016 Medicare Trustees report, the Medicare Part A Trust fund is solvent until 2028 (11 years longer than pre-Affordable Care Act (ACA)), due in large part to changes made in the ACA. We have serious concerns that the American Health Care Act repeals provisions in current law that have strengthened Medicare’s fiscal outlook, specifically, the repeal of the additional 0.9 percent payroll tax on higher-income workers. Repealing this provision could hasten  the insolvency of Medicare by up to 4 years and diminish Medicare’s ability to pay for services in the future.

Prescription Drugs

Older Americans use prescription drugs more than any other segment of the U.S. population, typically on a chronic basis. We are pleased that the bill does not repeal the Medicare Part D coverage gap (“donut hole”) protections created under the ACA. Since the enactment of the law, more than 11.8 million Medicare beneficiaries have saved over $26.8 billion on prescription drugs. We do have strong concerns that the American Health Care Act repeals the fee on manufacturers and importers of branded prescription drugs, which currently is projected to add $25 billion to the Part B trust fund between 2017 and 2026. AARP believes Congress must do more to reduce the burden of high prescription drug costs on consumers and taxpayers and is willing to work with you on bipartisan solutions.

Individual Private Insurance Market

About 6.1 million older Americans age 50-64 currently purchase insurance in the nongroup market, and nearly 3.2 million are currently eligible to receive subsidies for health insurance coverage through either the federal health benefits exchange or a state-based exchange (exchange). We have seen a significant reduction in the number of uninsured since passage of the ACA, with the number of 50- to 64-year-old Americans who are uninsured dropping by half.

Affordability of both premiums and cost-sharing is critical to older Americans and their ability to obtain and access health care. A typical senior seeking coverage through an exchange has a median annual income of under $25,000 and already pays significant out-of-pocket costs for health care. We have serious concerns that the bill under consideration will dramatically increase health care costs for 50- to 64-year-olds who purchase health care through an exchange due both to the changes in age rating from 3:1 (already a compromise that requires uninsured older Americans to pay three times more than younger individuals) to 5:1 and reductions in current subsidies for older Americans.

Age rating plus premium increases equal an unaffordable age tax. Our previous estimates on the age-rating change showed that premiums for current coverage could increase by up to $3,200 for a 64-year-old, while reducing premiums by only about $700 for a younger enrollee. Significant premium increases for older consumers will make insurance less affordable, will not address their expressed concern of rising premiums, and will only encourage a small increase in enrollment numbers for younger persons. In addition, the bill proposes to change current subsidies based on income and premium levels to a flatter tax credit. The change in structure will dramatically increase premiums for older consumers. We estimate that the bill’s changes to current law’s tax credits could increase premium costs for a 55-year-old earning $25,000 by more than $2,300 a year. For a 64-year-old earning $25,000 that increase rises to more than $4,400 a year, and more than $5,800 for a 64-year-old earning $15,000. When we examined the impact of both the tax credit changes and 5:1 age rating, our estimates find that, taken together, premiums for older adults could increase by as much as $3,600 for a 55-year-old earning $25,000 a year, $7,000 for a 64-year-old earning $25,000 a year and up to $8,400 for a 64-year-old earning $15,000 a year. In addition to these skyrocketing premiums, out-of-pocket costs could significantly increase under the bill with the elimination of cost sharing assistance in current law. The cost sharing assistance has provided relief on out-of-pocket costs (like deductibles and certain benefits) for low-income individuals who are some of the most financially vulnerable marketplace participants.

Medicaid and Long-Term Services and Supports

AARP opposes the provisions of the American Health Care Act that create a per capita cap financing structure in the Medicaid program. We are concerned that these provisions could endanger the health, safety, and care of millions of individuals who depend on the essential services provided through Medicaid. Medicaid is a vital safety net and intergenerational lifeline for millions of individuals, including over 17.4 million low-income seniors and children and adults with disabilities who rely on the program for critical health care and long-term services and supports (LTSS, i.e., assistance with daily activities such as eating, bathing, dressing, managing medications, and transportation).

Of these 17.4 million individuals: 6.9 million are ages 65 and older (which equals more than 1 in every 7 elderly Medicare beneficiaries); 10.5 million are children and adults living with disabilities; and about 10.8 million are so poor or have a disability that they qualify for both Medicare and Medicaid (dual eligibles). Dual eligibles account for almost 33 percent of Medicaid spending. While they comprise a relatively small percentage of enrollees, they account for a disproportionate share of total Medicare and Medicaid spending.

Individuals with disabilities of all ages and older adults rely on critical Medicaid services, including home and community based services (HCBS) for assistance with daily activities such as eating, bathing, dressing, and home modifications; nursing home care; and other benefits such as hearing aids and eyeglasses. People with disabilities of all ages also rely on Medicaid for access to comprehensive acute health care services. For working adults, Medicaid can help them continue to work; for children, it allows them to stay with their families and receive the help they need at home or in their community. Individuals may have low incomes, face high medical costs, or already spent through their resources paying out-of-pocket for LTSS, and need these critical services. For these individuals, Medicaid is a program of last resort.

In providing a fixed amount of federal funding per person, this approach to financing would likely result in overwhelming cost shifts to states, state taxpayers, and families unable to shoulder the costs of care without sufficient federal support. This would result in cuts to program eligibility, services, or both — ultimately harming some of our nation’s most vulnerable citizens. In terms of seniors, we have serious concerns about setting caps at a time when per-beneficiary spending for poor seniors is likely to increase in future years. By 2026, when Boomers start to turn age 80 and older, they will likely need much higher levels of service — including HCBS and nursing home — moving them  into the highest cost group of all seniors. As this group continues to age, their level of need will increase as well as their overall costs. We are also concerned that caps will not accurately reflect the cost of care for individuals in each state, including for children and adults with disabilities and seniors, especially those living with the most severe disabling conditions.

AARP is also opposed to the repeal of the six-percent enhanced federal Medicaid match for states that take up the Community First Choice (CFC) Option. CFC provides states with a financial incentive to offer HCBS to help older adults and people with disabilities live in their homes and communities where they want to be. About 90 percent of older adults want to remain in their own homes and communities for as long as possible. HCBS are also cost effective. On average, in Medicaid, the cost of HCBS per person is one-third the cost of institutional care. Taking away the enhanced match could disrupt services for older adults and people with disabilities in the states that are already providing services under CFC.

AARP has concerns with the removal of the state option in Medicaid to increase the home equity limit above the federal minimum. This takes away flexibility for states to adjust a Medicaid eligibility criterion based on the specific circumstances of each state and its residents beyond a federal minimum standard.

Although we cannot support the American Health Care Act, we are pleased that the bill does not repeal some of the critical consumer protections included in the Affordable Care Act, such as guaranteed issue, prohibitions on preexisting condition exclusions, bans on annual and lifetime coverage limits and allowing families to keep children on their policies until the age of 26. Also, AARP does support restoring the 7.5 percent threshold for the medical expense deduction which will directly help older Americans struggling to pay for health care, particularly the high cost of nursing homes and other long-term services and supports.