GOP Sen. Steve Daines frustrated by Republicans’ secrecy on Senate health care bill

Montana Sen. Steve Daines has joined other Senate Republicans in objecting to the way party leaders are crafting a major health care bill behind closed doors.

Daines told Lee Montana newspapers Friday that he hasn’t seen the bill, which Senate Majority Leader Mitch McConnell has indicated will get a vote in the next two weeks.

“I have been frustrated with the lack of transparency and the lack of visibility that we are having in this process,” Daines said. “I want to see a bill. Put down all these thoughts now in a bill so we can look at it. Then we can really have the best dialogue and conversation once you actually see it in a proposed law. It needs to be posted soon. I hope we get to see it next week.”

Daines said for the bill to work for Montanans, it's going to have to make health care more affordable. Health care expenditures are on track to become 20 percent of the U.S. economy. People with preexisting conditions are also going to need affordable coverage.

Daines and other Republicans contend that health costs have risen because of the Affordable Care Act passed by Democrats in 2010, though others argue that health care costs in the United States have been rising for decades. Concern over those rising costs is what made health care reform a key issue in the 2008 presidential campaign and a priority for President Barack Obama.

The ACA became commonly known as Obamacare, a term coined by Republican lawmakers who opposed the policy and vowed to repeal it, which they are now attempting to do.

Medicaid eligibility, expanded to include the working poor under the Affordable Care Act, needs to continue, Daines said, though the portion of the bill paid by the federal government will need to decrease.

“I want to make sure that we would not pull the rug out from Montana from a federal perspective and make sure that we keep our obligation to the states that have decided to expand Medicaid,” Daines said. “Whether you agree with Medicaid expansion or not, the bottom line is this: the state has decided to go forward on that, and I believe it’s the federal government’s responsibility to at least protect Montana through 2019 when Montana’s Medicaid expansion program sunsets.”

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Roughly 79,000 working Montanans with incomes within 138 percent of the federal poverty level - about $16,400 a year - have signed up for Medicaid since the state opted for an expansion program included in the Affordable Care Act. The federal government agreed to pay 100 percent of the expanded program’s cost for the first three years, with the federal share dropping into the 90s thereafter. Medicaid hadn’t been available to the working poor previously and the vast majority had no health care at all before the expansion.

Daines said Senate Republicans will allow states to continue the expanded Medicaid program - something House Republicans opposed in their plan, called the Affordable Health Care Act, which was passed earlier this spring to repeal and replace Obamacare.

The level of federal support for the program will decrease over a few years until by 2024 the federal government is paying 68 percent of the costs and states pick up the rest.

Much of the discussion surrounding the future of Medicaid expansion under Republican plans to replace the Affordable Care Act has assumed that expansion would stop in 2019 and that people who have taken advantage of Medicaid expansion would be pushed off the rolls. Daines said that’s not what the Senate bill will offer, at least not as it currently exists.

“There are those in the state who I think are putting out information that’s not entirely accurate, creating a lot of concern and fears that frankly do not align with where it looks like this bill text is headed at the moment,” Daines said.

Last week, the Montana Healthcare Foundation indicated the state would lose $4.8 billion in federal Medicaid funding between 2020 and 2026 under the Affordable Health Care Act passed by the Republican majority in the U.S. House.

That forecast is based on the House AHCA bill and does not reflect what the Senate might propose, said Aaron Wernham, Montana Healthcare Foundation CEO. Nothing is known about the Senate bill, Wernham said. The foundation, created by Blue Cross Blue Shield to explore affordable health care options for Montana, did not make a recommendation on what Congress should do, but did focus on the benefits of Medicaid expansion to Montana.

“From our standpoint, Medicaid expansion has done a very good job of doing what it needs to do,” Wernham said. “Since Medicaid expansion, our uninsured rate has dropped a lot, to 7.4 percent, which is compared to 11 percent nationally in 2016.”

Before Medicaid expansion the number of uninsured people in Montana was around 20 percent, Wernham said.

What Medicaid expansion has meant to Montana health care is to make sure that medical bills get paid and that more Montanans are practicing preventative care rather than turning up in emergency rooms with complications from untreated medical problems.

Medicaid coverage has been critical at RiverStone Health in Billings. Yellowstone County’s provider of essential public health services sees 20,000 people a year, said Barbara Schneeman. Medicaid pays the bill for 35 percent of the people, most of whom are children or people with disabilities. Visits to RiverStone number 71,000 annually.

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The non-Medicaid priorities for the Senate health care bill focus on lowering costs for the larger, healthier portion of Americans who don’t use insurance often. Republicans plan to use health savings accounts funded with pretax dollars to help healthier Americans cover costs, Daines said. HSAs have been around for 14 years and allow people to make tax-deductible contributions to accounts for spending on medical needs.

There’s no tax on the accounts as they grow. There are no taxes when the money is spent, provided the funds are spent on approved medical needs. Lawmakers in the House and Senate intend to beef up HSAs, which have been a staple of workplace health plans. Half of Americans rely on workplace health plans for insurance coverage.

“Health savings accounts have been shown to be a way to help drive, frankly, market pressures on the system where it gives consumers choice,” Daines said. Consumers spending money from HSAs while making medical decisions will seek the most affordable services.

Critics caution that HSAs are only useful if people can afford to invest. And HSAs work with lower- to average-cost medical expenses. Some expenses are too big for HSAs to cover. The funds are currently used by people with high-deductible insurance policies in which individuals must pay a higher amount of upfront medical costs before their insurance kicks in.

Another idea Senate Republicans are considering to drive down costs for private insurance in healthy populations is allowing the public to create larger private insurance pools than they have presently, Daines said.

People with preexisting conditions would then be put in a high-risk insurance pool, where the level of government support is higher to meet the medical costs of people with chronic health problems. Guaranteeing that health coverage is available for people with preexisting conditions is the goal.

House Republicans included a high-risk pool in their health care plan, but the funding provided was too low to meet demand. The Senate is still working on the backstop for its high-risk pool plan, Daines said.

Montana’s senior senator, Democrat Jon Tester, has criticized Republican plans to replace the Affordable Care Act, which Tester helped pass into law. Tester has said Republicans should focus on fixing the Affordable Care Act, rather than undermining it.

Many of the problems facing the ACA could have been fixed over the years since Republicans gained majority control of the Senate and House, Tester asserts. But Republicans have been unwilling to improve the ACA and have undercut it in some cases.

President Donald Trump has harmed the ACA by threatening to withhold $7 billion intended to lower consumer deductibles and copays, according to Tester.

Tester supports continuing Medicaid expansion, improving cost-sharing terms for copays and deductibles, while also covering essential benefits for mental health, prescription drugs and preventative care.

Tester wants to continue allowing adult children to stay on parents’ health plans until age 26, a feature House Republicans included in the AHCA.