Medicaid Archives - Florida Politics

State budget deal struck? Jack Latvala says, ‘no,’ but…

Updated 2:45 p.m. — The House has sent over an offer and the Senate is reviewing, according to staffers in both chambers.

After teetering toward a late-session meltdown, the bones of a roughly $83 billion 2017-18 state budget are in place, according to three sources close to Gov. Rick Scott‘s office and several lobbyists familiar with the negotiations.

Senate Appropriations Chairman Jack Latvala, however, early Tuesday morning said to “not believe the rumors.”

The budget framework, as it stands now, gives legislative leaders Richard Corcoran and Joe Negron their top priorities while delivering a likely-fatal blow to Enterprise Florida (EFI), the public-private economic development organization Scott wants full funding for.

Latvala even told Enterprise Florida interim CEO Mike Grissom Monday evening that a deal was coming together and Grissom “would not like it.”

Flexing their muscle, future Senate Presidents Bill Galvano and Wilton Simpson played pivotal roles in shaping the compromise plan, sources said.

There was bound to be horse-trading: The Senate agreed to fund the House’s “Schools of Hope” charter-school proposal and backed down on increased property taxes, while the House will go along with the Senate’s plan to revitalize Lake Okeechobee.

Negron’s $1.5 billion plan to help Lake O and stop overflows of toxic “guacamole water” into the state’s rivers and streams earlier passed the Senate 36-3. The Senate wanted to leave mandatory local property tax levels (“required local effort,” in Capitol parlance) where they are, to capture rising property values for school funding; the House sees that as a tax increase. Negron also gets more money for higher education.

But the deal also sets up a showdown with the Governor’s Office: Funding for Enterprise Florida, which gets far more public than private dollars, would be zeroed-out.

And VISIT FLORIDA‘s budget would be capped at $50 million, and House accountability measures for the public-private tourism marketing agency also would be put in place, including pay caps and limiting employees’ travel expenses.

The sticking point in all of this may be the torpedoing of EFI, explaining Latvala’s resistance to saying there is a deal. He’s carried Scott’s water in the Senate, but at this point he may willing to go along with a deal if, as those close to the negotiations suggest, the hundreds of millions of dollars in projects that his committee has shepherded get funded.

Unable to reach a deal over the weekend, the House offered a “continuation” budget that would have kept state funding intact at current levels in many places.

That would have allowed legislators to end the session on time and avoid the need for a costly special session. But it would have meant that there would be no money for any new projects.

The Senate rejected this idea. Negron, in a memo to senators Monday morning, called it a “Washington creation where Congress is habitually unable to pass a budget,” adding he had “no interest in adopting this ineffectual practice.”

Despite Senate opposition, Corcoran announced late Monday the House would pass a second budget that would freeze most spending and allow for some growth in Medicaid and public school spending. He said this budget would prevent a possible government shutdown later this summer.

“We remain hopeful that we will be able to reach an acceptable compromise,” Corcoran said in a memo to members. “It is our responsibility to pass a budget that continues the functions of state government.”

Material from the Associated Press was used in this post.

Bill Nelson presses Tom Price on Florida’s opioid crisis, Medicaid’s ability to fight it

In a letter sent today to U.S. Health and Human Services Secretary Tom Price, Florida’s Democratic U.S. Sen. Bill Nelson called attention to Florida’s heroin and opioids crisis and sought answers on how Medicaid can do more.

In his letter, Nelson declared that the heroin and opioid epidemic is “devastating Florida” and he encouraged Price and his agency to continue the fight against opioid abuse and misuse in the United States.”

“Addiction to heroin and opioids has reached staggering levels, and the situation is only getting worse. In 2015, more than 33,000 Americans died from an opioid overdose. That’s 15 percent more people who died from opioid overdoses than in 2014,” Nelson wrote. “The state of Florida is no exception to the national trend. More than 2,200 Floridians died of opioid abuse in 2015.”

He noted that Palm Beach County Vice Mayor Melissa McKinlay‘s effort to get Gov. Rick Scott to declare a public health emergency, and Congress’s efforts to push a comprehensive approach and provide additional funding to approach opioid abuse.

Now Nelson challenged Price to consider Medicaid’s role, and to support efforts to retain Medicaid’s opportunities, even against proposals pushed by Republicans in Congress and in Tallahassee.

“As the single largest payer for substance use services, Medicaid plays a critical role in the fight against the opioid epidemic,” Nelson wrote. “Changing the Medicaid program through block grants or caps will shift costs to states, eliminate critical federal protections, and hurt the more than 3.6 million Floridians who rely on the program, including those struggling from opioid disorders.

“If those cuts are made, how do you propose states like Florida provide the necessary services to help individuals with substance use disorder?” Nelson inquired.

Then he turned to the Medicaid expansion program included in the Affordable Care Act, noting that Florida declined it, leaving an estimated 309,000 low-income Floridians with mental health or substance abuse disorders without easy access to affordable health care.

According to a study by Harvard University and New York University, Medicaid expansion provides drug treatment to nearly 1.3 million Americans,” Nelson wrote. “If Florida expanded its Medicaid program, would it be able to increase access to treatment for those with opioid use disorder? And would expanding Medicaid help the state avoid the rising costs associated with the opioid crisis and mental health needs?

Rick Scott, feds agree to $1.5B commitment for low income pool in Florida

The Trump administration is coming through with $1.5 million in new health care money for Florida, Gov. Rick Scott announced Wednesday as the House and Senate debated their rival spending plans for 2017-18.

The money will finance Florida’s Low Income Pool, which reimburses hospitals that provide charity care.

The infusion would “truly improve the quality and access to health care for our most vulnerable populations,” Scott said in a written statement.

“It is great to have a partner in Washington who is willing to work with us to help our state,” the governor said.

“Florida was on the front-line of fighting against federal overreach under President Obama, and it is refreshing to now have a federal government that treats us fairly and does not attempt to coerce us into expanding Medicaid.”

“This is great news — good news all around,” said Sen. Anitere Flores, chairwoman of the budget subcommittee on health care, who’d included $600 million in LIP money in the Senate budget in hopes the feds would provide it.

“This is a much larger amount of LIP funding than we ever have received. We were not expecting this level of funding. But I think that’s a testament to our congressional delegation being more involved and aware of the importance of this.”

House budget chairman Carlos Trujillo was more circumspect. His committee never counted on the federal money.

“I don’t think there’s a place to spend that much money,” he told reporters.

“It’s good. Florida was punished for years by the prior administration. It’s good that the current administration is recognizing that Medicaid expansion and LIP funding are two separate conversations,” Trujillo said.

The money would allow the House to find other uses for money it would have put into charity care, he said. “We would probably like to use it either for tax cuts or put it straight into reserves, and shore up some more reserves for the out years,” he said.

“From day one, we have been committed to working with our state partners to ensure they have the flexibility they need to make decisions that best reflect the unique needs of their populations,” U.S. Health and Human Services Secretary Tom Price said.

“Today’s announcement reflects that commitment on the part of the Trump administration. We look forward to continuing to work with Gov. Scott as well as governors across the country to make sure Americans have access to quality health care.”

The Obama administration started withholding the money after Florida refused to accept the Medicaid expansion under the Affordable Care Act.

Senate Appropriations Chairman Jack Latvala informed the Senate of the news during debate on the chamber’s $82.3 billion budget for 2017-18.

The House was debating its own $81.2 billion budget Wednesday.

A group of hospitals that spend heavily on charity care welcomed the news.

“The LIP funding helps our safety net hospitals carry out their mission of providing highly specialized, expensive and primary care to all citizens, regardless of their ability to pay,” said Tony Carvalho, president of the Safety Net Hospital Alliance of Florida.

State officials have long complained that Florida draws less than its fair share of federal health care dollars.

“A state like Texas would get almost double what we would get in LIP. This is something that has been needed for a long time,” Flores said. “There has definitely been a disparity.”

It was too early to say how the cash would affect budget negotiations with the House, she said.

“I would hope that, No. 1, that the House would be open to receive this funding,” Flores said.

“Does it open the door for other health care issues? It might. But at the very minimum … it’s for our hospitals. This is great news in a year where, initially, even in the governor’s budget, they had been looking at close to $1 billion in cuts,” she said.

Also party to the announcement were Centers for Medicare & Medicaid Services Administrator Seema Verma and Justin Senior, secretary of Florida’s Agency for Health Care Administration.

“Centers for Medicare and Medicaid Services is working toward a new era of state flexibility and leadership,” Verma said.

“For too long states have been sharing in the cost but have not been allowed to have a meaningful role in decision-making. We want to provide states the flexibility to make health care decisions that best meet their citizens’ unique needs, and support states covering access to health care services.”

“We truly feel like our federal partners are listening to our state and our needs and we know that Florida will have the flexibility we need to run our Medicaid program as efficiently as possible while providing the highest level of care in our state’s history,” Senior said.

Emmett Reed: Who best entrusted with senior care – caregivers or insurers?

Emmett Reed is executive director of the Florida Health Care Association.

In an effort to protect their turf, the health plans behind Florida’s managed care program for Medicaid recipients keep saying they help many older Floridians move from nursing homes to live in community settings. What they fail to tell you is that these elders are just a small fraction of nursing home residents – the reality is that some frail elders simply cannot be properly cared for outside a skilled nursing center.

These health plans, along with the state Agency for Health Care Administration, are basing their assessment on seriously flawed calculations. While they say it would cost taxpayers $200 million to remove skilled nursing centers from managed care, such a carve-out would actually save taxpayers $68.2 million per year.

Florida has a long-standing commitment to helping elders stay in their homes or community settings for as long as possible. But we must also recognize that for more and more of the frailest residents, a nursing home is the best, and perhaps only, realistic option.

The state’s erroneous cost estimate is based on an assumption of what it would cost if certain individuals who received home- and community-based services had instead been cared for in a nursing center. But the proposed carve-out focuses solely on exempting long-stay nursing center residents, not those who could otherwise live in community settings. There are no savings to be realized for these individuals because their health and medical needs can only be addressed in a nursing center – they cannot be safely cared for in a home or community setting.

Official state figures show that managed care companies transition only about 4 percent of nursing center residents into home- and community-based care. That means the other 96 percent continue to receive their care in skilled nursing centers. The huge savings touted by the managed care companies simply cannot be realized.

Florida’s system of managed care doesn’t work effectively for long-stay nursing center residents, who can’t take care of themselves or be safely cared for in the community. With those residents stuck in the managed care system, taxpayers are paying approximately $68.2 million in unnecessary fees each year for management services that are not needed, according to a study for the Florida Health Care Association.

In the final analysis, managed care companies are more like insurance companies than like health care providers – if it doesn’t work for their bottom line, they’re not interested. So when your loved one needs the kind of care that can only be offered in a skilled nursing facility, who would you rather entrust with their care: their insurer or their trained caregivers?

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Emmett Reed is executive director of the Florida Health Care Association.

trauma centers

Safety net hospitals decry Medicaid spending cuts planned for Florida

Representatives of hospitals that invest heavily in physician training and care for the indigent held a news conference Monday to protest plans in the Legislature to slash Medicaid re-imbursement rates.

The cuts would undermine the state’s investments in training doctors, alliance members argued outside the Senate Office Building in Tallahassee.

Under the Graduate Medical Education Startup Bonus Program launched by Gov. Rick Scott two years ago, teaching hospitals draw $100,000 bonuses for every residency they add in key specialties. New residencies totaled 313 this year.

“We cannot train tomorrow’s physicians when every year our hospitals must re-evaluate their budgets,” said Lindy Kennedy, vice president for government relations for the Safety Net Hospital Alliance.

Steven Sonenreich, president and CEO of Mount Sinai Medical Center, cited a study showing that 80 percent of doctors remain in the state where they were trained.

“United States veterans wait 75 days on average to see a psychiatrist. There is a severe shortage in this state in many specialties, including the number of psychiatrists that we train,” Sonenreich said.

“Budget cuts to our institutions are felt when people are calling to make doctors appointments. It is that simple,” he said.

Training doctors without properly funding the hospitals where they would work “makes little fiscal sense,” said Leon Haley, dean of the UF College of Medicine-Jacksonville.

“To do so is to effectively spend taxpayers’ money to educate other states’ doctors,” Haley said.

The pressure on hospital budgets is coming from all sides — Scott’s proposed budget would cut $929 million from in Medicaid re-imbursements, paying 58 cents for every dollar the hospitals spend, alliance members said.

The House would cut $672 million, paying 62 cents on the dollar, and the Senate would cut $309 million, paying 68 cents.

Hospitals would be forced to pass some of their losses along to privately insured patients, alliance president Tony Carvalho said. The “hidden tax” would cost $2.7 billion under the governor’s plan, $2.4 billion under the House’s, and $2.13 billion under the Senate’s.

“These costs do not evaporate … because the hospital is reimbursed less than the cost of providing that care,” Carvalho said.

Approximately 4.5 million Floridians will participate in Medicaid next year, and 2.5 million uninsured, he said.

“That’s 6.5 million people — or almost one-third of the population — that when they get sick and come to a hospital, we can expect to get paid less than cost or nothing at all,” he said.

Additionally, the state would forego $414 million in federal matching funds under the House bill, Carvalho said. The Senate would give back nearly $200 million. All while state officials complain the feds shortchange Florida in health care money.

“It seems a contradiction in terms … to be forfeiting hundreds of millions in federal money for a very small savings in the General Revenue Fund,” Carvalho said.

Finally, the cuts would disproportionately harm safety net hospitals that care for most poor and indigent patients, he said.

The alliance comprises 14 public, teaching, and children’s hospitals that provide most of the bonus residencies and almost half the state’s Medicaid and indigent care.

Poll: 45% of Florida voters would like to see increase in Medicaid funding

A new survey from the Florida Hospital Association shows strong support among Florida voters to keep — or in many increase — state funding for Medicaid programs.

The survey, conducted by Public Opinion Strategies from March 1 through March 5, found Floridians have the most favorable opinion of Medicaid that the association has recorded in six years. The poll of 600 registered voters found 56 percent said they had a favorable opinion of Medicaid, up from 47 percent in a November 2011 survey.

The results of the survey come as state lawmakers began releasing their initial budget recommendations, which included taking away as much as $621.8 million from hospitals in the coming year.

The House proposal cuts the state’s share of Medicaid by $238.6 million, or a total of $621.8 million once federal dollars are factored in. The Senate has recommended cutting $99.3 million, or a $258.6 million total cut.

But the Florida Hospital Association found that while the state is slashing budgets, many Floridians would actually like to see lawmakers keep funding as is, if not give the programs funding boost.

According to the survey, 45 percent of Floridians said they would like to see Medicaid funding increased, while 29 percent said they believe state funding should stay the same. Just 8 percent said funding for the programs should be decreased.

Six years ago, 47 percent of Floridians supported keeping the funding the same, while 39 percent wanted to see more money put into the program. Back in November 2011, 11 percent of Floridians supported decreasing funding for Medicaid programs.

When respondents were asked about a few specific areas the Legislature will be spending money on this year, 61 percent of Floridians said the state should increase funding for Medicaid, which provides health care to lower-income children, the disabled elderly, and pregnant women.

Voters also supported increasing funding for water quality problems (67%); the state’s colleges and universities (52%); tax cuts to help business to expand or relocate to Florida (31%); and tourism promotion (23%).

Yet when asked whether they would support redirecting money from Medicaid to help pay for increased funding for colleges and universities, tax cuts for businesses, and tourism promotion, 75 percent of voters said they would advise their legislator to keep the money in Medicaid programs.

There appeared to be broad support to keep money in Medicaid programs, with 68 percent of Republicans, 85 percent of Democrats, and 73 percent of independents saying they would advise their legislator to keep funding Medicaid.

That feeling was echoed throughout the state, with a solid majority of voters in each media market saying the Legislature keep money for Medicaid.

The highest support for keeping the cash for Medicaid came from the Jacksonville area, where 80 percent of respondents said they wanted legislators to keep money for Medicaid programs.

The Fort Myers media market — which includes Gov. Rick Scott’s hometown of Naples — had the highest percentage of people saying they should shift the funds, with 20 percent of respondents saying they would tell their lawmaker to use it for something else.

 

Joe Henderson: Psst … Tallahassee, you might want to actually listen to the people on this one

While the business of governing requires tough choices and choosing between priorities that can be conflicting, sometimes it’s best to do what the people want. After all, it’s their money that is being spent.

So, listen up, Tallahassee.

On the subject of state Medicaid funding, the people — your bosses — appear to have spoken loudly, clearly and with a you-better-not-mess-with-this message. They want it funded, and they’re not kidding.

According to a Public Opinion Strategies poll conducted for the Florida Hospital Association and shared with FloridaPolitics.comabout three-quarters of the 600 registered voters surveyed like their Medicare and Medicaid. They strongly reject shifting funds from those programs to other spending projects.

And this is most telling — of those voters who accept the state might have a budget crisis, 66 percent say Medicare and Medicaid shouldn’t be cut.

This comes as budget proposals in the House and Senate call for steep cuts in those programs.

Well, well, well!

Budget hawks in the Legislature have grumped for years about the expense of these programs, but they’re missing the point. As this poll appears to show, the people are telling legislators that this point is nonnegotiable.

Lawmakers can get away with a lot of things because voters are consumed by the act of living day to day. Most voters don’t tune into all the nuance and back-and-forth that goes on in the Legislative Session, but they’ll damn sure pay attention if their Medicaid is threatened.

While the moves by House Speaker Richard Corcoran to tighten lobbying rules and eliminate Gov. Rick Scott’s business incentives were politically shrewd and had the added benefit of being the right thing to do, I doubt voters in the Villages or anywhere else in the state discussed it at happy hour.

Health care coverage is so complicated, though, that can’t be solved with barroom chat or by taking a meat cleaver to vital programs. Sometimes, leaders just have to do what the people want.

This also isn’t something where politicians can reasonably expect people to do more with less. If lawmakers don’t yet know that, let ‘em whack the Medicaid budget. Watch what happens when their constituents can’t afford or, in some cases, even get services they were used to.

That’s what this survey was telling state leaders as they grapple with how to set and pass a budget. They better be listening.

Audrey Brown: Long-term care key to quality of life for Florida Medicaid seniors

Audrey Brown, president and CEO of Florida Association of Health Plans, Inc.

In 2011, the State of Florida elected to move long-term care (LTC) into the Statewide Medicaid Managed Care (SMMC) program, as the escalating costs of providing care at more institutional-style settings, like nursing homes, to an aging baby boomer population was creating a looming health care crisis.

For most families, the decision to move a loved one to a nursing home or institutional setting is difficult and saddening.  Many people would prefer to be at home and not institutionalized, if at all possible; but, until the implementation of the SMMC program, the hope of transitioning out of a facility was dim and the possibility of having the necessary services to keep someone at home was slim.

The fundamental strategy to allow Florida’s health plans to coordinate long-term care for our state’s most vulnerable and frail Medicaid beneficiaries was to enhance care in institutional settings, while simultaneously reducing the reliance on nursing homes by increasing the utilization of appropriate community-based alternatives.

Since its implementation, the program has been successful, as the LTC program now works both in terms of achieving cost savings and expanding meaningful benefits.  First and foremost, this program delivers the right amount and type of care to address individuals’ needs.  Often this appropriate type of care is delivered through more cost-efficient, home-based care services, which not only offers a less-restrictive setting for those eligible, but has also resulted in more than $400 million in cost savings.

Moreover, health plans have been able to leverage their resources to offer expanded benefits, such as support to transition to the community; emergency financial assistance; dental, hearing and vision services; transportation and many more.  These expanded benefits were valued at $9.5 million in 2015 and are financed by the health plans — not taxpayers.  Further demonstrating its success, 77.4 percent of Medicaid LTC recipients recently indicated in a survey that their quality of life has improved as a result of the SMMC LTC program.

Despite these documented successes and high satisfaction rates, some have expressed interest in regressing to the old model, wherein more of Florida’s most vulnerable populations would once again remain in institutional settings, where they are often not better served, with fewer opportunities to transition to more appropriate, less restrictive settings.

The Agency for Health Care Administration (AHCA) also recently took a look at the impact that regressing to the old fee-for-service model would have on the state and found that the result would be calamitous.  Noting in a bill analysis, AHCA said that this move would result in additional costs amounting to $284 million for FY 2014-2015, $432 million in FY 2015-2016 and an estimated ongoing cost avoidance of $200 million annually.

Further, to demonstrate the real-world benefits Florida’s health plans deliver to patients, including in LTC, the Florida Association of Health Plans, Inc. (FAHP) recently launched a campaign, Florida Patients Matter, which showcases a series of videos focused on health plans’ commitment to being patient-centered.  In one video, a health plan member, Carol, discusses how after being diagnosed with stage four Non-Hodgkin lymphoma, she was successfully transitioned home after being in a nursing home for three and a half years. Carol, now in remission, receives in-home care and assistance with medication, setting up doctor appointments and more from her health plan.

As Florida lawmakers discuss long-term care this session, FAHP urges them to keep the current LTC program in place, as it is truly improving the quality of life for seniors and their families.

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Audrey Brown is president and CEO of Florida Association of Health Plans, Inc.

White House, in gamble, demands make-or-break health vote

Abandoning negotiations, President Donald Trump demanded a make-or-break vote on health care legislation in the House, threatening to leave “Obamacare” in place and move on to other issues if Friday’s vote fails.

The risky move, part gamble and part threat, was presented to GOP lawmakers behind closed doors Thursday night after a long and intense day that saw a planned vote on the health care bill scrapped as the legislation remained short of votes amid cascading negotiations among conservative lawmakers, moderates and others.

At the end of it the president had had enough and was ready to vote and move on, whatever the result, Trump’s budget director Mick Mulvaney told lawmakers.

“‘Negotiations are over, we’d like to vote tomorrow and let’s get this done for the American people.’ That was it,” Rep. Duncan Hunter of California said as he left the meeting, summarizing Mulvaney’s message to lawmakers.

“Let’s vote,” White House chief strategist Steve Bannon said as he walked out.

“For seven and a half years we have been promising the American people that we will repeal and replace this broken law because it’s collapsing and it’s failing families, and tomorrow we’re proceeding,” House Speaker Paul Ryan said, then walked off without answering as reporters demanded to know whether the bill had the votes to pass.

The outcome of Friday’s vote was impossible to predict. Both conservative and moderate lawmakers had claimed the bill lacked votes after a long day of talks. But the White House appeared ready to gamble that the prospect of failing to repeal former President Barack Obama‘s health law, after seven years of promising to do exactly that, would force lawmakers into the “yes” column.

“It’s done tomorrow. Or ‘Obamacare’ stays,” said Rep. Chris Collins, R-N.Y., a top Trump ally in the House.

Collins was among those predicting success Friday, but others didn’t hide their anxiety about the outcome.

Asked whether Republicans would be unified on Friday’s vote, freshman Rep Matt Gaetz of Florida said, “I sure hope so, or we’ll have the opportunity to watch a unified Democratic caucus impeach Donald Trump in two years when we lose the majority.”

Thursday’s maneuvers added up to high drama on Capitol Hill, but Friday promised even more suspense with the prospect of leadership putting a major bill on the floor uncertain about whether it would pass or fail.

The Republican legislation would halt Obama’s tax penalties against people who don’t buy coverage and cut the federal-state Medicaid program for low earners, which the Obama statute had expanded. It would provide tax credits to help people pay medical bills, though generally skimpier than Obama’s statute provides. It also would allow insurers to charge older Americans more and repeal tax boosts the law imposed on high-income people and health industry companies.

The measure would also block federal payments to Planned Parenthood for a year, another stumbling block for GOP moderates.

In a concession to the conservative House Freedom Caucus, many of whose members have withheld support, the legislation would repeal requirements for insurers to cover “essential health benefits” such as maternity care and substance abuse treatment.

The drama unfolded seven years to the day after Obama signed his landmark law, an anniversary GOP leaders meant to celebrate with a vote to undo the divisive legislation. “Obamacare” gave birth to the tea party movement and helped Republicans win and keep control of Congress and then take the White House.

Instead, as GOP leaders were forced to delay the vote Thursday, C-SPAN filled up the time playing footage of Obama signing the Affordable Care Act.

“In the final analysis, this bill falls short,” GOP Rep. Jaime Herrera Beutler of Washington state said in a statement Thursday as she became the latest rank-and-file Republican, normally loyal to leadership, to declare her opposition. “The difficulties this bill would create for millions of children were left unaddressed,” she said, citing the unraveling of Medicaid.

In a danger sign for Republicans, a Quinnipiac University poll found that people disapprove of the GOP legislation by 56 percent to 17 percent, with 26 percent undecided. Trump’s handling of health care was viewed unfavorably by 6 in 10.

House Minority Leader Nancy Pelosi, D-Calif., who as speaker was Obama’s crucial lieutenant in passing the Democratic bill in the first place, couldn’t resist a dig at the GOP disarray.

“You may be a great negotiator,” she said of Trump. “Rookie’s error for bringing this up on a day when clearly you’re not ready.”

Obama declared in a statement that “America is stronger” because of the current law and said Democrats must make sure “any changes will make our health care system better, not worse for hardworking Americans.” Trump tweeted to supporters, “Go with our plan! Call your Rep & let them know.”

Unlike Obama and Pelosi when they passed Obamacare, the Republicans had failed to build an outside constituency or coalition to support their bill. Instead, medical professionals, doctors and hospitals — major employers in some districts — as well as the AARP and other influential consumer groups were nearly unanimously opposed. So were outside conservative groups who argued the bill didn’t go far enough. The Chamber of Commerce was in favor.

Moderates were given pause by projections of 24 million Americans losing coverage in a decade and higher out-of-pocket costs for many low-income and older people, as predicted by the nonpartisan Congressional Budget Office. In an updated analysis Thursday, the CBO said late changes to the bill meant to win over reluctant lawmakers would cut beneficial deficit reduction in half, while failing to cover more people.

And, House members were mindful that the bill, even if passed by the House, faces a tough climb in the Senate.

Republished with permission of The Associated Press.

Donald Trump to Capitol in last-ditch lobbying for health care bill

President Donald Trump is rallying support for the Republican health care overhaul by taking his case directly to GOP lawmakers at the Capitol, two days before the House plans a climactic vote that poses an important early test for his presidency. Top House Republicans unveiled revisions to their bill in hopes of nailing down support.

At a rally Monday night in Louisville, Kentucky, Trump underscored what he called “the crucial House vote.”

“This is our long-awaited chance to finally get rid of Obamacare,” he said of repealing former President Barack Obama‘s landmark law, a GOP goal since its 2010 enactment. “We’re going to do it.”

 Trump’s closed-door meeting with House Republicans was coming as party leaders released 43 pages worth of changes to a bill whose prospects remain dicey. Their proposals were largely aimed at addressing dissent that their measure would leave many older people with higher costs.

Included was an unusual approach: language paving the way for the Senate, if it chooses, to make the bill’s tax credit more generous for people age 50-64. Details in the documents released were initially unclear, but one GOP lawmaker and an aide said the plan sets aside $85 billion over 10 years for that purpose.

The leaders’ proposals would accelerate the repeal of tax increases Obama imposed on higher earners, the medical industry and others to this year instead of 2018. It would be easier for some people to deduct medical expenses from their taxes.

Older and disabled Medicaid beneficiaries would get larger benefits. But it would also curb future growth of the overall Medicaid program, which helps low earners afford medical coverage, and let states impose work requirements on some recipients. Additional states could not join the 31 that opted to expand Medicaid to more beneficiaries under Obama’s law, the Affordable Care Act.

In a bid to cement support from upstate New Yorkers, the revisions would also stop that state from passing on over $2 billion a year in Medicaid costs to counties. The change was pushed by Rep. Chris Collins, R-N.Y., one of Trump’s first congressional supporters. Local officials have complained the practice overburdens their budgets.

Republican support teetered last week when a nonpartisan congressional analysis projected the measure would strip 24 million people of coverage in a decade. The Congressional Budget Office also said the bill would cause huge out-of-pocket increases for many lower earners and people aged 50 to 64.

Democrats have opposed the GOP repeal effort. They tout Obama’s expansion of coverage to 20 million additional people and consumer-friendly coverage requirements it imposed on insurers, including abolishing annual and lifetime coverage limits and forcing them to insure seriously ill people.

The GOP bill would dismantle Obama’s requirements that most people buy policies and that larger companies cover workers. Federal subsidies based largely on peoples’ incomes and insurance premiums would end, and a Medicaid expansion to 11 million more low-income people would disappear.

The Republican legislation would provide tax credits to help people pay medical bills based chiefly on age, and open-ended federal payments to help states cover Medicaid costs would be cut. Insurers could charge older consumers five times the premiums they charge younger people instead of Obama’s 3-1 limit, and would boost premiums 30 percent for those who let coverage lapse.

House approval would give the legislation much-needed momentum as it moves to the Senate, which Republicans control 52-48 but where five Republicans have expressed opposition. Trump used Monday’s trip to single out perhaps the measure’s most vociferous foe — Kentucky GOP Sen. Rand Paul.

“He’s a good guy,” Trump said of one 2016 rival for the GOP presidential nomination. “And I look forward to working with him so we can get this bill passed, in some form, so that we can pass massive tax reform, which we can’t do till this happens.”

Enactment of the health care bill would clear the way for Congress to move to revamping the tax code and other GOP priorities. Defeat would wound Trump two months into his administration and raise questions about his ability to win support from his own party moving forward.

Among the disgruntled were GOP lawmakers in the hard-right House Freedom Caucus, though the strength of their opposition was unclear. The group has seemed to have around 40 members, but that number may be lower now and some have expressed support or an open mind for the bill.

Caucus leader Rep. Mark Meadows, R-N.C., an outspoken opponent, said the group was not taking a formal position on the measure. That could indicate that a significant fraction of its members were not willing to vow “no” votes.

Meadows said he believes the House will reject the bill without major changes.

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Reprinted with permission of the Associated Press

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