The Republican reform that pbaded through the Senate early Saturday would profoundly reach the nation's health system, with a clear indication of a central aspect of the Affordable Health Care Act and wider expansive effects that could threaten other programs over time .
The measure would abolish the application by the government of the ACA requirement that most Americans have insurance coverage. It would not end the individual mandate in itself, but it would eliminate the fiscal sanctions for breaching that requirement. The result could mean that 13 million additional people do not have insurance and increase insurance premiums in the markets created by law, according to a calculation by non-congressional budget badysts.
However, the side effects of the project may have attracted less attention. harm the health care and well-being of many more people. The Senate plan would increase the federal deficit from the current fiscal year and, unless lawmakers intervene, would unleash a budget sequence of events that would reduce billions of dollars of Medicare and public health services. The reductions would be derived from a "pay per use" law that basically requires compensation to increase federal spending.
At the same time, frantic negotiations to align support for mbad legislation within the reduced majority of the Senate improved prospects for temporarily reactivating payments to the ACA insurers that President Trump ended this fall. By becoming the last Republican senator to announce support for the tax bill, Senator Susan Collins (Maine) said Friday afternoon that Majority Leader Mitch McConnell had "committed to support" two separate measures before the end of year.
is a bipartisan plan that would restore "shared cost reduction" payments for two years to cover the cost of the discounts that the ACA requires insurers to grant to low-income clients with deductibles and other out-of-pocket costs. . Trump cut the monthly payments starting in October, mistakenly calling them "bailouts" to the insurance industry. The plan, forged by Sens. Lamar Alexander (R-Tenn.) And Patty Murray (D-Wash.), Would also expand the ability of consumers to purchase low-cost "catastrophic" health plans through the ACA markets. and it would make it easier for states to secure federal permission to carry out the basic ideas of the law in different ways.
An attempt to approve the plan failed in the Senate in the early fall, but Collins said Friday that McConnell was willing to support his approval, along with a newer plan. that would give the states two years of money for various "reinsurance" funds meant to help insurers cushion premium increases. No measure has been considered by the House.
Now that both houses of Congress have approved versions of the largest rewriting of tax legislation in decades, the differences will have to be negotiated. The House bill would not end the penalties for Americans who do not have insurance, but Republicans have sympathized with the idea, which was part of legislation pbaded by the House this year to dismantle much of the ACA.
The probability of large reductions in other forms of health spending, triggered by the so-called PAYGO law to deter deficit increases, is less certain.
In the hours leading up to the Senate's final vote on the fiscal review package, McConnell and House Speaker Paul D. Ryan (R-Wis.) Tried to quell fears of such cuts by issuing a joint statement in the one that accused the Democrats of "misleading statements" and promised to "work to ensure that these spending cuts are avoided."
The bill itself does not prevent them, however. Subsequently separate actions would be required and, unlike the parliamentary maneuvers used to adopt the tax plan with only votes from the Republican Party, they would require the support of some Democrats. Republican leaders predict that Democrats will cooperate rather than blame for damaging health care funds.
The joint statement of the leaders has its skeptics. "We are aware that they say they will give up PAYGO, but we have little consolation that they can do this," said Georges S. Benjamin, executive director of the American Public Health Association. "Why did not you write the bill to address this in the first place?"
The cuts, if they happen, would lower federal spending on Medicare by 4 percent, which amounts to about $ 25 million next year, the Congressional Budget Office predicted. Because the PAYGO rules do not allow Medicare benefits to be affected, the loss of funds will be distributed between payments to doctors, hospitals and others who provide care to the 56 million senior and disabled Americans in the program.
Those standards focus solely on spending within the federal budget and leaving intact some health care programs that help low-income Americans, such as Medicaid and the Children's Health Insurance Program. But it could eliminate almost $ 1 billion per year for a Public Health and Prevention Fund, created under the ACA, which now accounts for 12 percent of the budget of the Centers for Disease Control and Prevention.
If that fund goes away, "people will be sicker," Benjamin warned, with fewer low-income Americans likely to get a bad or colon cancer test and public health workers with less ability to control outbreaks. contagious infections  Even if PAYGO cuts are averted, advocates of vulnerable groups of Americans fear that the magnitude of the increased deficit in the $ 1.5 trillion bill in the next decade will give conservatives in Congress a reason to reduce the social security programs that have waited for a long time to aim.
"That is ultimately the most problematic part," said David Certner, legislative adviser to AARP. "We create these big deficits and that will put pressure on the cuts to Medicare and Medicaid … Everything will be on the table."
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