Snyder warns Michigan lawmakers about Obamacare overhaul

March 21--WASHINGTON -- Gov. Rick Snyder, reaching out to Republican members of Michigan's congressional delegation on Tuesday, never specifically asked them to reject a GOP plan to replace the Affordable Care Act, but he reminded them individually -- with statistics specific to their districts -- of the tens of thousands of Michiganders who could lose coverage if they support it.

"Altogether, there are 1.75 million children, seniors, pregnant women and disabled individuals served by traditional Medicaid in Michigan and roughly 104,000 of them reside in your district," he wrote U.S. Rep. Tim Walberg, R-Tipton, in a letter representative of those he sent out. The legislation, he went on to say, "will adversely impact them."

But even as Snyder warned members of the consequences of passing the legislation -- including changes that may gut funding for Healthy Michigan, the state's Medicaid expansion program that has insured some 650,000 lower-income Michiganders, and cut support for the traditional Medicaid program as well -- many of the state's Republican members of the U.S. House continued to voice their support for the plan.

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"Medicaid is not on sustainable financial footing and it cannot stay intact if we continue to kick the can down the road," said U.S. Rep. Mike Bishop, R-Rochester. "A major part of our health care reform package is about preserving and strengthening programs like Medicaid for years to come and not to pull the rug out from under anyone who currently relies on this assistance."

Added U.S. Rep. Paul Mitchell, R-Dryden, "This is not the first issue on which I disagree passionately with the governor. This is a rescue mission. Allowing the system to continue to collapse will result in even fewer choices and, eventually, a lack of access to care."

Snyder's effort represented a key moment in the debate over repealing the ACA, also known as Obamacare, with the Republican governor saying the proposal by House Speaker Paul Ryan would hike costs for older Michiganders and leave thousands of poor residents without coverage.

"In its current form, the (plan) shifts significant financial risk and cost from the federal government (to) the states," Snyder said in letters to the entire delegation but intended specifically for the nine Republican members. "While reforming the nation's health care system is vital, it is imperative that gains in health coverage and access to care are maintained."

Democrats are expected to vote as a bloc against Ryan's plan, which could come to vote as early as Thursday. Republicans can afford only about 20 defections overall if they are to pass the legislation on to the Senate and make good on a promise to repeal and replace the ACA. Ryan and other leaders believe they have the votes, but other reports have suggested it could be close.

Under Ryan's proposal, which is intended to maintain access to coverage while cutting back sharply on the federal government's financial responsibility for it, people without employer coverage buying insurance on state exchanges who make up to a certain income level -- $75,000 for individuals, $150,000 for couples -- would still get tax credits to offset their premiums but those would be determined by age instead of income. Insurance companies would also gain more flexibility in writing policies and charging older Americans more -- up to five times more -- than younger ones.

The Congressional Budget Office has said the proposal -- which would save as much as $337 billion over 10 years compared to the ACA -- could generally lower insurance premiums overall for Americans buying on the exchanges in the years to come, though older residents, especially those with lower incomes, would generally see premiums increase, a change Snyder said he remains "concerned about."

The replacement plan, as initially written, also pulled back Medicaid expansion authorized under the ACA and enacted in 31 states, including Michigan.

Under changes put forward Monday night by Ryan, states would be able to continue receiving 90% of the funding for people currently on those programs -- which cover people making up to 138% of the federal poverty limit -- but new enrollees after Jan. 1, 2020, would be covered at the state's traditional Medicaid rate of about 65%.

Over a short period of time, most people currently on Healthy Michigan would cycle off, analysts have found, with others taking their place. But because those new enrollees would be funded at a less-generous amount, it would leave the states to either pick up the difference or close their programs.

Also disruptive is a provision that in 2020 would set Medicaid funding for each state at an amount based on the per-capita costs in the program from an earlier year, then basing any increases each year on the number of people in the program multiplied by that per-capita figure as well as any hikes in the consumer price index.

The Congressional Budget Office has noted that since the consumer price index grows more slowly than Medicaid expenses, over time states would get less than the amount it costs to continue coverage, forcing programs to scale back or states to add more of their own funding. Ryan's changes Monday night also allow for states to opt for a "flexible block grant" that would allow greater freedom in its use. It would not grow on a per-capita basis from year to year, however, regardless of the demand, instead relying solely on increases in the consumer price index.

By enacting such limits, spending -- at both the state and federal levels -- could decrease. But coverage would be expected to be scaled back as well, Snyder said.

Snyder's individual letters to each member of Congress, pointing out exactly how many people receive Medicaid benefits in his or her district and saying the proposed American Health Care Act "will adversely impact them," was intended to underscore the stakes involved.

"The proposed legislation reduces federal resources that our state relies on to assist 2.4 million Michiganders enrolled in traditional Medicaid and the Healthy Michigan plan," Snyder wrote, adding his belief that "reform must be approached deliberately" to ensure that "our most vulnerable citizens do not fall through the cracks."

Democrats were supportive of the governor, even if many Republicans were not.

"Received letter from @onetoughnerd on his opposition to #Trumpcare. Agree w/ the Governor -- MI GOP delegation should oppose this bad bill!" U.S. Rep. Dan Kildee, D-Flint Township, wrote on Twitter, referring to Snyder's own Twitter handle.

While Republican members of the U.S. House remained largely in support of Ryan's plan, there are political risks at home: According to figures provided by the state, there are some 343,000 Healthy Michigan recipients living in Republican-represented districts, compared to 308,000 in Democratic-represented ones.

Also, looking at data from March 2016 reported by the Kaiser Family Foundation, there were also some 210,100 people who had purchased coverage under the state's exchange living in Republican-represented districts compared to 103,000 people living in Democratic-represented ones in Michigan.

Some Republicans with particularly large numbers from both were U.S. Rep. Jack Bergman, R-Watersmeet, whose Up North district includes some 44,000 Healthy Michigan recipients and had 31,000 people with insurance purchased on the exchange last year. Walberg's south-central Michigan district included 49,000 Healthy Michigan recipients and 19,600 people who got insurance on the exchanges.

Closer to Detroit, Mitchell's district -- centered in northeastern Macomb County and up through the Thumb -- had 36,000 Healthy Michigan recipients and 26,700 people who bought insurance on the exchanges. Bishop (31,000) and U.S. Rep. Dave Trott, R-Birmingham, (24,000) had the smallest numbers of Healthy Michigan recipients in the state and only about 24,000 constituents buying on the exchanges each. Still, seeing that number of people threatened with losing coverage could have political consequences.

Figures -- especially for Healthy Michigan -- were far higher in most individual Democratic-represented districts, especially the two touching Detroit. But because there are fewer Democratic districts than Republican districts across the state, Republican-represented districts accounted for more of both Medicaid expansion recipients and exchange purchases statewide.

Not all Republican lawmakers are supportive of Ryan's plan -- U.S. Rep. Justin Amash, R-Cascade Township, has railed against the current proposal as "Obamacare 2.0," saying the federal government should not be in the business of providing health care. But most, if not all, others from Michigan are backing it, including U.S. Rep. John Moolenaar of Midland, who said Tuesday he was in support and chided Snyder by saying, "State governments need to stop looking at federal funding as free money."

Bergman and Walberg did not comment on any support for the plan following Snyder's letter. But U.S. Rep. Bill Huizenga, R-Zeeland, said by altering the plan, Ryan has followed through on a promise to "modernize the Medicaid program." Tom Wilbur, a spokesman for U.S. Rep. Fred Upton, R-St. Joseph, said Upton has worked to make sure Snyder had "a voice" in the deliberations but that he still supports the bill.

"As we move forward in this process, Fred looks forward to working with all of the governors to make improvements and provide more flexibility to the states," Wilbur said.

In his letter, Snyder said the way state law is written, the Healthy Michigan expansion would be be terminated under the current proposal because of the cost shift. He added that while Congress and the Trump administration may follow through on guarantees to provide greater resources to the state he "cannot rely solely on the promise of future action without seeing all the tools that will be at our disposal to manage the program."

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Snyder has generally been supportive of Republican efforts to rewrite the Affordable Care Act in recent months, meeting with Trump administration officials and key lawmakers on Capitol Hill. After those meetings, he acknowledged that Obamacare was in trouble, with premiums increasing and insurers dropping out from the marketplace exchanges.

But he has also insisted throughout that states need the resources and ability to maintain coverage they have already provided for efforts such as Healthy Michigan, which he has touted as a model for the nation, saying it has reduced expensive hospital visits through a formula that lowers recipients' costs for healthy behaviors.

Contact Todd Spangler: 703-854-8947 or at [email protected]. Follow him on Twitter at @tsspangler.

Gov. Snyder's letter to Sen. Debbie Stabenow:

Gov. Snyder's letter to Rep. Walberg

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