New Mexico Study: Working Individuals Make Up the Largest Group Who Benefit from Medicaid Expansion 

Study Estimates that 56 Percent of those benefiting from New Mexico’s Medicaid Expansion are Working Adults in Key Economic Sectors

More than 90,000 New Mexicans benefiting from the state’s decision to accept Medicaid expansion work in industries that are the foundation of the state’s economy, with jobs ranging from sales and food service to construction and health care, according to estimates in a study released today by Families USA. 

This projected group of working New Mexicans represents an estimated 56 percent of the state’s residents who benefit from New Mexico’s Medicaid expansion, which went into effect last year. 

“These statistics are an important part of the story about Medicaid in New Mexico,” said Barbara Webber, Executive Director of Health Action NM, a non-profit health consumer advocacy organization based in Albuquerque, NM. “We are thrilled that Centennial Care, including the very important Medicaid expansion for adults in our state, has contributed to the significant increase in health coverage for hard working families.  

“This improved health access will certainly mean better health status for working families and increased productivity for the industries they represent,” Webber said. “This proves that Medicaid has been a win-win situation for New Mexico.”

Without Medicaid expansion, many of these people would have fallen through the cracks in the health care system – making too much for traditional Medicaid, but too little to qualify for subsidies on the insurance exchange, said Ron Pollack, executive director of Families USA.

“This study shows Medicaid expansion is a success story in New Mexico,” Pollack said. “The people it helps have tough jobs in industries that traditionally don’t provide health insurance. Now after a hard day’s work, they can sleep with the peace of mind that health insurance provides – knowing that a sudden accident or illness won’t wipe out their savings and dreams for the future.” 

“Governor Martinez should be congratulated for her initial decision to expand Medicaid,” Pollack said. “The numbers contained in this study show how important this program is for so many of the working people of her state.”

Under Medicaid expansion, which went into effect in 2014, states can offer Medicaid coverage to residents with incomes up to 138 percent of the federal poverty level, which is $27,720 for a family of three. For the first three years, the federal government pays 100 percent of the costs. Starting in 2017, states will begin paying a small portion of the costs, which will be capped at 10 percent in 2020.

We are honored to announce that the keynote address at Health Action NM's 20th Anniversary Celebration Dinner will be presented by a national leader in consumer health advocacy, Mr. Ron Pollack, Founder and Executive Director of Families USA.  Mr. Pollack has been recognized for many achievements, which include being appointed by President Clinton as the sole consumer representative on the Presidential Advisory Commission on Consumer Protection and Quality in the Health Care Industry, successfully arguing two cases on the same day in the U.S. Supreme Court to secure food aid for low-income Americans, and the successful federal litigation that resulted in the creation of the WIC program for malnourished mothers and infants.  He was also instrumental in the creation of Health Action NM.

How it all started

Health Action NM’s roots lie in the reaction to proposals that would dismantle the social safety net in the United States.  In the mid-90’s, there was a serious effort to severely cut and privatize Medicare and Medicaid, monumental programs that effectively provide financial security and access to health care for millions of Americans.  A grassroots movement formed throughout the nation to protect these programs during this time of great uncertainty.  Central to this effort was Ron Pollack, who was called “a real whipper-snapper” by Mandy Pino, one of Health Action NM’s founders.

Building a movement

Throughout the nation, Mr. Pollack organized advocates to oppose efforts to weaken or eliminate public health coverage programs.  Among the advocates were three New Mexicans: Mandy Pino, Pat Bartels, and Ellen Leitzer.  Together, they formed the Committee to Preserve Medicare and Medicaid. “Families USA identified or created small groups throughout the nation to protect these programs” says Pino, “and that’s how Health Action NM started.”  For the first several years, the committee worked on a completely volunteer basis to advocate at the local and national level to protect essential programs and create new protections for patients and consumers. That committee eventually became Health Action NM and spurred the creation of the New Mexico Health Care for All Coalition.

From organizing to action
By the late 1990’s, Health Action NM was officially formed and brought together community activists and policy experts to advocate for better health care policies.  Community forums were held throughout the state to bring consumer testimony directly to state officials.  In 1998, Ellen Pinnes was hired as Health Action NM’s first official paid staffer and worked with Jim Jackson and other co-chairs to pass the Patient Protection Act, a historic patient bill of rights that was passed by the state legislature.  These advocates also worked to create a community foundation with funds from the conversion of the Blue Cross/Blue Shield New Mexico in to a for-profit entity.  In 2002, that foundation became the Con Alma Foundation, which now distributes in excess of $1 million annually to community-based health care organizations.  The organization then worked to develop a blueprint to improve New Mexico’s health care system for the next several years.

National health reform
During the debate around health reform, Health Action NM engaged communities around to state to educate people about the most promising ideas in health policy.  Upon the passage of the Affordable Care Act, our staff worked tirelessly to advocate for policies that the state could adopt to better serve people in New Mexico during the law’s implementation. Working alongside incredible partner organizations, Health Action NM advocated for and secured the expansion of Medicaid, the creation of the New Mexico Health Insurance Exchange, and a process to review and reject unjustified health insurance premium hikes.  By 2013, Health Action NM assembled a statewide field team in conjunction with local partnerships to organize outreach and enrollment efforts. 

20 more years of success
It is incredible to look back at all of the stories, people, and places that went in to creating this organization.  Our team couldn’t be more thrilled to honor those who have made such a substantial impact on our state’s health care system for the good of the people.  We hope you will join us in celebrating 20 years of advocating for consumers, increasing access to health care, and engaging with communities in New Mexico in their own health.  We’re looking forward to 20 more.  Cheers!

This week instead of reviewing stories, we have decided to post the remarks prepared by former State Senator Dede Feldman in regards to the 50th Anniversary of Medicare and Medicaid.  The remarks were presented at the Health Care for All Coalition's Medicare and Medicaid celebration on July 30th, 2015.   They provide an encapsulating view of the history of health coverage expansion, the challenges of acheiving full universal coverage, and the path towards that goal.  We hope you enjoy her brilliant insights as much as we do.

Former State Senator Dede Feldman

Thank you to the New Mexico Health Care for All Coalition. What a great pleasure it is to be with you here today, as we celebrate the anniversary of Medicare and Medicaid. Since I left the legislature a few years ago, more and more I find myself mulling over the historical and social context of what happens in Santa Fe and Washington. So in that vein, I ask you to take a little stroll down memory lane with me…. Starting with 1964, the year before Congress passed Medicare. The average price of a new house was about $13,000; a postage stamp was 5 cents; and a loaf of bread a quarter.  Congress passed the Golf of Tonkin resolution and the war in Vietnam was heating up.  There was historic Civil Rights legislation, and it was the year the Beatles invaded the US.

I was a senior in high school that year, and on the debate team.  The national question was “Resolved that social security benefits should be extended to medical care for Americans over 65.” I remember vividly the debates, the note cards I meticulously compiled pro and con.  It was easy to assemble the con position form the huge number of TV and radio ads, the white papers put out by the AMA, all warning of a soviet style model of medical care. They were the same warnings of rationing, of socialism, of the dangers of some health authority dictating the terms of the most intimate areas of American life that I heard 40 years later in the legislature as I pushed for more health care coverage—by any means necessary.  

Here are a few of the clips from that time:

Ronald Reagan: “[I]f you don’t [stop Medicare] and I don’t do it, one of these days you and I are going to spend our sunset years telling our children and our children’s children what it once was like in America when men were free.” [1961]

Barry Goldwater: “Having given our pensioners their medical care in kind, why not food baskets, why not public housing accommodations, why not vacation resorts, why not a ration of cigarettes for those who smoke and of beer for those who drink.” [1964]

The passage of Medicare in 1965 was not an isolated event. It was the culmination of over a half-century of work, by people who believed in universal health insurance, starting with Teddy Roosevelt and the Bull Moose Party in the early 1900s, FDR who shelved it to get social security, and especially Harry Truman who sent Congress its first comprehensive proposal. 

It was Harry Truman that President Lyndon Johnson honored fifty years ago today when he traveled to Independence Missouri to sign the Medicare bill. One person who was at his side was New Mexico Senator Clinton Anderson, who played a key role in the early ‘60s.  Anderson sponsored a Medicare bill in 1962.  It was a key priority of the newly elected president, John F. Kennedy, but it was defeated by two votes in the Senate after a barrage TV and radio ads of phone calls and the first “Astroturf” campaign of canned letters to congress drummed up by the AMA.  But the tide of public opinion was turning. Proponents continued to struggle for it in Congress. In1964, two separate bills passed both the House and the Senate.  But the conference committee was not able to agree—I hope you’re seeing some parallels with the Affordable Care Act here—and so the measure died, again.

But after Lyndon Johnson received 60% of the vote in the fall of 1964, and Goldwater was defeated, the handwriting was on the wall.  This time, in 1965, the conference committee’s report was adopted on July 27 and 28th. And the rest is history.

But it’s a different kind of history than those legendary lawmakers would have expected.  Now Medicare and Medicaid are not social insurance programs, strictly run out of Washington.  They are largely private programs, run by insurance companies and the states, the subjects of constant financial worry and political pressure.

Of course, the authors of Medicare, and later, Medicaid did know what health care reformers today have learned, with the passage of the Affordable Care Act and other reforms.    That each victory is part of a progression of smaller steps, one building upon one another.  Sometimes in the slow process, it seems like we are going backward, exerting all our efforts just to prevent the dismantling of what those policy makers gathered in Missouri staked their reputations, their positions, and the efforts of a lifetime on.

 But in the ensuing twenty years we have built on their efforts, starting the Children’s Insurance Program, most recently expanding Medicaid to 800,000 recipients in New Mexico, adding a drug benefit to Medicare, imperfect as it is, and passing the Affordable Care Act, which will be celebrated 50 years from now as another giant step along the road to comprehensive and health care coverage. 

We all know that there are many challenges ahead for Medicare and Medicaid—how to bend the cost curve in the face of the onslaught of new baby boomers? How to negotiate for lower prescription drug prices?  How to prevent fraud and abuse? Or streamline the huge Medicaid bureaucracy, which rests on an outdated waiver system that costs states million to prove what they already know is working.  But we also know that the route to reshaping the delivery system, moving away from fee for service, and moving toward a more accountable and equitable system starts with Medicare and Medicaid.

 But today, today shows us, that the arc of history does bend toward justice, toward what Johnson called in the same speech “a triumph of rightness in America.”  So, thank you, it’s great to be a part of this stream of history with you today. 

- Dede Feldman, Former New Mexico State Senator and Author of “Inside the New Mexico Senate: Boots, Suits, and Citizens"

 

 

To improve health and save money we need to start thinking about policies that address the social determinants of health. The glaring irony of the American health care system is that we spend so much more than any other county on health care and have no substantially improved outcomes to show for it.  That realization can boggle the mind, but it starts to make sense when you look at our approach to other public programs linked to health.  The United States spends about half as much of our GDP on social services, such as nutritional assistance programs and supportive housing programs, than our European and Scandinavian counterparts. Studies consistently find that well-structured, basic social services can be incredible investments that pay themselves off in a variety of ways, one of which is reduced health costs.  It’s time to get serious about investing in programs that simultaneously improve health and save money.

 - Barbara Webber, Executive Director

It's unwise to impose Medicaid premiums and co-pays.  Several states have asked the Department of Health and Human Services for permission to charge Medicaid beneficiaries premiums and co-pays to keep their coverage active.  The report finds that even small payments are enough to deter people who are struggling to make it day-to-day from retaining coverage and seeking necessary medical care.  When people are forced to reject one basic need to meet another, we can be certain of a negative outcome.  Moreover, the proposed payment increases would be so small that they would barely affect the state’s budgets while adding a huge administrative burden on the state. We must maintain the integrity of public programs that improve people’s health.

- Joe Martinez, Outreach Coordinator

Medicaid expansion enrollees cost more than anticipated – but not for long.  Initially, it was estimated that Medicaid beneficiaries would cost 1% less than those on traditional Medicaid but new data reveals that costs were 19% higher than those of traditional Medicaid.  How could that be?  It turns out that there was a lot of pent up demand for medical services that people couldn’t access without health coverage.  The report indicates that costs are expected to fall substantially by 2016, once beneficiaries have met their basic health needs.  It should be noted that all years of higher-than-expected spending will occur when the federal government pays for the full costs of expansion.  The actuarial analysis found that there would be no effect on state budgets.  The report also found that the cost of program as a whole is well under recent projections. Medicaid is living up to its promise of giving low-income people greater access to health care services and more control over their health.

- Colin Baillio, Communications and Outreach

Anthem and Cigna strike $54.2 billion deal.  This is the largest buyout in the history of the health insurance industry.  It raises worries among consumer health advocates because consolidation often leads to higher premiums – and for all the wrong reasons.  As Sarah Kliff points out, mergers increase insurance carrier’s ability to negotiate lower prices with providers while also leading to higher premiums.  The benefits of greater negotiating power ought to be passed on to consumers in the form of lower premiums and out-of-pocket costs, as they are in Medicare and Medicaid and single-payer health coverage systems.  The government must now decide if the Anthem-Cigna merger violates antitrust laws.  Consolidation in the health care system should be approved only if there is a guaranteed benefit for consumers.

- DeAnza Sapien, JD, State Advocacy Coordinator 

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Health Action NM has had a busy month!  A range of issues have come about, requiring advocacy at all levels - community, regulatory, and legislative.  We have been attending community rallies & hearings to urge the governor not to make it harder for people in New Mexico to afford food, preparing for the health insurance premium rate review process to keep premium hikes in check, and working on proposals to fund the state’s 5% portion of the Medicaid expansion in 2017.

And all the while, we have been planning two big celebrations: The 50th Anniversary of Medicaid & Medicare (July 30th at Explora) and Health Action NM’s 20th Anniversary (September 26th at the Sheraton Uptown Albuquerque).

Community Advocacy: Opposing Work Requirements for SNAP

Hunger is a health issue.  As our own Joe Martinez said at a hearing last week, “Hungry children are not healthy children.  Hunger rapidly impacts the health of the person.”  Yet even as our economy struggles to create jobs, the governor has proposed work requirements for the Supplemental Nutritional Assistance Program, impacting up to 80,000 people who are already working so hard to make ends meet.  Now is not the time to even consider making it more difficult to access food.  Health Action NM has formally submitted comments in opposition to the regulations.

Regulatory Advocacy: Keeping Premiums Affordable

Health Action NM worked to establish the health insurance premium rate review process in New Mexico in 2012.  The process gives the Office of the Superintendent of Insurance the authority determine whether rate hikes truly reflect the costs of medical care and coverage.  Our staff is working with other partners to review the numbers from each insurance carrier to determine whether or not recent rate increases are justified.  Health Action NM will work with the Superintendent to ensure that consumers are represented in this process.

Legislative Advocacy: Funding the Medicaid Expansion

The costs of the Medicaid expansion have been fully covered by the federal government since the expansion began in January of 2014.  In 2017, the state will have to pay for 5% of the costs, scaling up to 10% of the costs by 2020.  Historically, New Mexico has paid nearly 30% of the cost of traditional Medicaid, so only paying 10% is a great deal for the state.  Medicaid has had huge benefits for New Mexico.  That’s why it is imperative that we maintain the integrity of the program as we fulfill the promise our state committed to when it expanded Medicaid.

Given the impact expansion has had on state revenues as a result of the up to $8.6 billion in increased economic activity, the $60 million in savings already recognized in the state budget, savings from reductions in uncompensated care, additional revenues from increased enrollment in private health plans, and revenue from expansion-driven jobs growth, the expansion of health coverage has largely paid for itself.

Even so, Health Action NM has been exploring other options for funding the expansion to ensure that the integrity of the program is not weakened.  One proposal that recently caught our attention was put together by a coalition that has formed around increasing the tax on alcohol in New Mexico.  Our state leads the nation in alcohol-related deaths, spending over $1.8 billion a year on the harms of alcohol.  Research suggests that the proposed tax increase would save 52 lives in the first year and save even more each following year, greatly decrease youth alcohol use, and prevent alcohol dependency for tens of thousands of people living in New Mexico.  

The coalition proposes that the legislature appropriate funds from an increased alcohol tax to fund the Medicaid expansion, strengthen existing alcohol prevention and treatment programs, and reimburse cities and counties for the costs of alcohol-related harms.  The coalition meets the second Wednesday of every month.  If you are interested in becoming involved in the coalition, please contact Peter DeBenedittis (alcoholtaxessavelives@gmail.com).

Dental Therapy: The Swinomish Tribe Hires a Dental Therapist

Brian Cladoosby - Photo by Mark Trahant

 

The Swinomish Indian Tribal Community in the Pacific Northwest has exerted its sovereignty by choosing to train and hire a dental therapist to practice on its tribal grounds.  “Oral health is essential to overall health,” said Brian Cladoosby, Chairman of the Swinomish Indian Tribal Community. “We cannot have healthy communities without access to reliable, high quality and culturally competent dental care.” 

As in New Mexico, tribal advocates in Washington State have played a crucial role in a broad coalition that has fought to license dental therapists for the past five years. After so many years of frustration with a federal law that restricts tribal sovereignty, the Swinomish Tribe has taken actions in to its own hands. This is an exciting development for advocates working to improve access to oral health services and tribes throughout the nation looking to provide culturally competent care for their people.

Upcoming Events

1) 4th Annual Native Youth Leadership Summit: July 28-31 @ Tamaya Resort & Spa
2) State Innovation Model Meeting: July 29th 2-4 @ The United Way Conference Room from 4-6 pm
3) 50th Anniversary Celebration of Medicare and Medicaid: July 30th @ Explora from 4-6 pm
4) NMHIX Board Meeting: July 31st @ The Indian Pueblo Cultural Center at 8:30 am
5) Beer for a Better Burque: August 3rd @ Tractor Brewery in Nob Hill & Wells Park from 3 pm - 12 am
6) Stakeholders Advisory Committee: August 13th @ ABQ Hispano Chamber of Commerce from 10 am – 12 pm
7) Health Action NM’s 20th Anniversary Celebration: September 26th @ Sheraton Uptown Albuquerque at 5:30pm

The Obama Administration submits workaround for Hobby Lobby ruling.  In 2014, the Supreme Court determined that employers could reject covering contraception for employees on religious grounds.  The case, known as Hobby Lobby v Burwell, has the potential to restrict millions of women’s access to contraception.  Now, the Obama Administration has submitted the final rules to ensure that any person that needs contraceptive coverage has access to it.  The proposed rule respects the court’s ruling while creating a way for employees to get the coverage they need.

Here’s how it works: An eligible company that objects to contraception needs to inform the Department of Health and Human Services (HHS) of its objection.  HHS will then designate the insurance carrier to provide the coverage directly rather than through the employer.  This will give employees a way to access the coverage they need while respecting the religious beliefs of employers as defined by the court.

- Barbara Webber, Executive Director

Texas-based organization pens op-ed in ABQ Journal about how ACA is bad for Latinos in New Mexico – they’re wrong.  Daniel Garza of the Libre Initiative claims that the Affordable Care Act (ACA) has failed to live up to its promises, particularly for Hispanics.  He cites the recent proposed premium hikes and access issues with Medicaid.  Of course, he fails to mention that in 2015 New Mexico had one of the lowest pre-tax credit premiums for Silver benchmark plans in the nation.  And on that note, Mr. Garza says nothing about the availability of premium tax credits that ensure premiums remain affordable.  The average premium tax credit in New Mexico is $200 a month.  If the lowest priced plan is, as Mr. Garza claims, $199 a month then that's great news for consumers in New Mexico.

Also missing is any mention of the rate review process, which Health Action NM worked to establish, that is currently being undertaken by the New Mexico Office of the Superintendent of Insurance (OSI).  This process allows the insurance department to open insurance carrier’s books to prevent unjustified premium hikes. 

In fact, this year’s rates are shaping up to be lower than 2014’s rates. In 2015 rates went down 11.8% and 2016 rates are expected to increase about 11%.  And that’s before OSI reviews the rates and carriers consider how premium stabilization programs affect their bottom lines (which was released after  these rates were proposed).

  
by Kaiser Family Foundation

Mr. Garza’s claims on Medicaid ignore the incredible economic and health benefits that the Medicaid expansion has had for New Mexico.  Medicaid is actually a highly efficient program that offers a comprehensive range of benefits at a much lower cost than private insurance.  Medicaid is a good example of how we can better control the cost of health care in the US. 

If anything, New Mexico needs to do a better job of directing outreach to Hispanics and beef up enrollment assistance to guide them through the options that now exist.  Our staff’s analysis indicates that just over 10,000 Hispanics signed up for marketplace coverage in New Mexico.  Given the portion of the population that Hispanics make up, those numbers should be much higher.  For a real take on how the Medicaid expansion and health insurance exchange has impacted Hispanics and other ethnic minorities, read DeAnza’s story of the week.  Health Action NM will continue to provide accurate information on the ACA for Hispanics and all people living in New Mexico.

- Colin Baillio, Communications and Outreach

New Data Show ACA Enrollment for Communities of Color.  For the first time, we have data showing enrollment numbers by race and ethnicity for individual counties in states that use healthcare.gov.  The evidence shows that the Affordable Care Act’s marketplace coverage options have been a boon for millions of people across our country, particularly for communities of color, who have struggled with pervasive health disparities and higher rates of uninsured people compared to non-Hispanic whites.  In fact, the reduction in the rate of uninsured Latinos and African Americans over just the last two years significantly outpaced whites—the rate dropped 12.4 percent and 9.2 percent respectively compared to 5.3 percent for whites. This is welcome news for the hundreds of national, state, and local organizations that conducted concerted outreach and enrollment efforts in minority communities across the country.  Still, there is much work to do to raise awareness about the benefits available on the marketplace among hard-to-reach populations in New Mexico and cover all who are eligible.

- DeAnza Sapien, State Advocacy Coordinator

Despite weak job growth, Governor Martinez proposes work requirements for the Supplemental Nutrition Assistance Program.  Governor Martinez has proposed regulations that would impose stringent work requirements on SNAP benefits for
- teenagers without children 16 to 18
- adults without children age 50 to 60
- adults 16 to 60 who have children over age six

Given that nearly every sector of the economy is barely adding any jobs and that much of our workforce is aging, now is not the time to even consider regulations that make it more difficult for New Mexico’s people to afford food.  I was able to submit the following comments to the NM Human Services Department (HSD) at a recent hearing:

“We are blessed with many things in New Mexico . . . our people of many cultures, of many languages, people of many talents.  And we are blessed by the many people in state government who work with their heart and their administrative skills to assist those who need essential, basic help such as food assistance.  We are blessed to have many state people all over the state to administer this assistance to help people who are hungry.

So, my appeal is to your heart . . . people in state government.  The new proposed rules for SNAP are an administrative strategy to make it harder . . . , in fact, to make it impossible for people who are already struggling to provide for their families to keep getting food assistance!  Who will be harmed?   Many, many children, and parents, and seniors.

Hungry children are not healthy children.  Hunger rapidly impacts the health of the person.

So, I appeal to you State of New Mexico, don’t do these new rules.  They will hurt those who are hungry.  They will add to the struggle for survival for so many in New Mexico!  Instead, use your state talents to create livable wage jobs.  And hire the unemployed to use their talents to serve others, and not have to be in need of SNAP.

Finally, please do something very healthy for your heart . . . and don’t require these new rules!”

Health Action NM’s staff has submitted comments to HSD urging them not to leave New Mexicans hungry.  We encourage you to do the same by the end of the day by emailing comments to HSD-isdrules@state.nm.us

As early as this Monday, the Supreme Court is expected to issue a ruling on a case that would strip health insurance subsidies from 6.4 million people.  The plaintiffs in the case, which is called King v Burwell, claim that Congress intended to withhold subsidies from states that chose not to establish a state-based health insurance exchange.  Though the history of the Affordable Care Act’s (ACA) passage suggests that this was never the case, there are signs that the Supreme Court may indeed strip subsidies from states with federally facilitated marketplaces.  

Consumers in New Mexico are protected from a bad decision since our state operates a state-based exchange, but it has the potential to negatively affect New Mexico in a number of ways, depending on how Congress handles the fallout of the decision.  President Obama has called on Congress to simply fix the language in the ACA to clarify that the subsidies are available to all states.  However, congressional Republicans are seeking to extract concessions in exchange for a continuation of subsidies.  Instead of re-capping the news of the week, Health Action NM has thoroughly investigated the concessions being called for by congressional Republicans and the implications that they have for consumers.

 Repeal the Individual Mandate

The Individual Mandate, which requires all Americans to acquire health coverage or else pay a penalty, has long been a target for repeal since it is the most unpopular part of the ACA.  However, it is the glue that holds the rest of the law together, including the popular components such as a ban on denying insurance based on pre-existing conditions, guaranteeing that consumers can purchase any coverage that they want, and ending the practice of charging women more than men for insurance.  

Without the individual mandate, the incentive to purchase insurance would be greatly weakened, creating a dysfunctional market in which only the sickest consumers sign up for coverage.  This would cause premiums to soar, causing more consumers to drop out of the market, leading to what economists call a death spiral.  The nonpartisan Center for Budget and Policy Priorities estimates that 22 million fewer uninsured people would be able to access insurance without the Individual Mandat

Repeal the Employer Mandate

The Employer Mandate requires all companies with 50 full-time employees or more to offer affordable health coverage to employees.  According to the US Treasury Department, 96% of businesses in the US are exempt from the Employer Mandate because they have less than 50 employees.  96% of those that are required to offer coverage already do so and less than .2% of firms are expected face fines for not offering coverage.

The reason lawmakers included the Employer Mandate in the ACA was to ensure that companies didn’t drop their employee’s coverage and push them on to individual marketplace.  A repeal of the provision has serious budgetary considerations as well.  It would increase the amount spent on subsidies because more people would get coverage on exchanges that offer coverage.  Still, it would not shake the ACA at its core the way a repeal of the Individual Mandate would. 

 Repeal the Medical Device Tax

 The Medical Device Tax applies a 2.3% tax on medical device manufacturers’ sales. The ACA is designed to reduce the deficit even as it expands coverage.  To do that, lawmakers cut spending in some areas and increased revenues on industries that stood to benefit from the law.  Since medical device manufacturers enjoy some of the greatest profit margins in the health care industry and stood to greatly benefit from increased utilization of their products as a result of the ACA’s coverage expansion, lawmakers included this tax as a way to finance the law.  

Many have claimed that the tax gets passed on to consumers through increased prices, though Consumers Union (a consumer advocacy organization) disagrees, given the high profit margins and rate of growth that medical device manufacturers enjoy and the benefits it will reap from the ACA.  Repealing the Medical Device tax would increase the deficit by $26 billion between 2015-2024, unless Congress could make up for the loss of revenue by increasing taxes or decreasing spending in other areas. 

Repeal the Independent Payment Advisory Board

The Independent Payment Advisory Board (IPAB) is a committee of experts that would be convened if Medicare spending grew at an exorbitant rate.  IPAB has not yet been convened because of the recent slowdown in health spending.  If triggered, IPAB would be tasked with finding ways to restrain spending without impacting Medicare benefits.  Congressional Republicans have long sought to repeal IPAB, claiming that it will lead to rationing of care, restrict Congress’ role in Medicare, and give bureaucrats too much control over patients.

However, the ACA specifically prohibits IPAB from rationing care, increasing premiums or cost sharing, cutting benefits, or limiting eligibility.  Cost controls can only achieve savings through payment and delivery reforms. Congress will still play a central role in Medicare policy when IPAB is active.  If Congress can produce equivalent savings, IPAB’s recommendations won’t go in to effect.  It is likely to be the most effective cost containment program built in to the law and is vital to the sustainability of Medicare.  Future generations need access to this important program for seniors and IPAB will play a critical role in ensuring the its integrity.

Repeal the Cadillac Tax

The Cadillac Tax refers to a 40% excise tax on health plans with unnecessarily excessive benefits. It is designed to discourage employers from offering benefits that drive up costs for everyone else and raise revenues to increase health coverage.  Congressional Republicans claim that the tax limits employers’ ability to compete for employees on benefits and restricts access to the high quality health coverage.  

In the 2008 presidential campaign, John McCain proposed ending the $250 billion a year tax break on employer sponsored health insurance to finance a new health care program.  The Cadillac Tax achieves a similar result, only on a much smaller scale and on the upper echelon of high-end plans offered by employers. 

Reduce Subsidies

Currently, those making under 400% of the Federal Poverty Level (FPL) are eligible for premium tax credits under the ACA.  Some congressional Republicans have proposed that those subsidies be reduced, limited to those under 300% FPL, be based on age rather than income, and be a fixed dollar amount rather than based on the cost of insurance.  This would seriously weaken the effect subsidies have on access to affordable insurance, especially for low and moderate income households.  The way subsidies were initially designed was to ensure longterm affordability for individuals and families across the economic ladder.  Reducing financial assistance just as so many have begun to feel the security of health coverage would be irresponsible and detrimental to consumers.