Trump Could Undermine Health Programs Outside Budget Cuts, Democrats Warn

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By Alex Ruoff

House Democrats are worried President Donald Trump’s federal budget released May 23 revealed he’s unwilling to support a number of popular public health programs.

The White House’s proposed fiscal 2018 budget included more than $11 billion in cuts for the Department of Health and Human Services. Nearly $7 billion of that cut would come from the National Institutes of Health, according to budget documents.

The White House also proposed trimming $600 billion from Medicaid over the next 10 years, which would come on top of the more than $800 billion slated to be cut from the federal-state insurance program for the poor under House Republicans’ Obamacare repeal bill.

Several leading Republicans have indicated these cuts are unlikely to be included in next year’s federal spending bill. However, Democrats are warning the president’s budget demonstrates he’s not interested in supporting the public health and insurance programs that millions of Americans rely on.

“We’re all very concerned about what these agencies can do in a different way to undermine the effectiveness of a lot of these programs we care about,” Rep. John Yarmuth (D-Ky.), ranking member of the House Budget Committee, told reporters May 23.

Democrats plan to question agency heads in weeks to come about how they will roll out certain public health programs, such as the White House Office of National Drug Control Policy, which is a major player in the fight against the opioid epidemic.

Lawmakers also plan to question the head of the Centers for Medicare & Medicaid Services about how the federal government will fund and oversee state Medicaid programs, according to Democratic congressional aides.

Public Health

Public health groups are likewise raising alarm bells over the $1.2 billion cut proposed for the Centers for Disease Control and Prevention as well as the proposal to eliminate funding for the Agency for Healthcare Research and Quality.

Such cuts would hit immunization programs and health research the hardest, Emily Holubowich, executive director for the Coalition for Health Funding, which advocates for AHRQ programs, told Bloomberg BNA May 23.

“This budget request would be laughable if it weren’t so dangerous,” Holubowich said in a statement. “At best, it represents a fundamental ignorance about the comprehensive role of government in protecting and promoting America’s health. At worst, it represents a wanton disregard for American’s health security.”

Groups working to educate Americans about vaccines first grew concerned about the federal government’s commitment to some federal vaccine programs after reports that Trump and his team have repeatedly met with people who claim there’s a connection between childhood vaccines and autism. These groups are keeping a close eye on how the administration and Congress fund vaccine programs, which are supported by the CDC, in coming years.

There is an annual battle between advocates and appropriators over how much money is needed to support the federal vaccination program, known as the 317 Program. In 2016, appropriators funded the program at roughly $610 million, well below the CDC’s request of $930 million, according to agency budget documents.

Exchange Funding

Budget authority of $471 million was requested for the health insurance exchanges by the Centers for Medicare & Medicaid Services in the HHS budget-in-brief. Of that total, $453 million supports program operation activities such as eligibility, call center operations and information technology, the document said.

In addition, the CMS anticipates collecting approximately $1.2 billion in user fee revenues to support exchange activities, it said. The total estimated program level, which includes sources from other accounts, is $1.7 billion, it said.

The exchange funding “appears to be flat” from the Obama administration budget for fiscal 2017, Elizabeth Carpenter, a senior vice president at health-care consulting firm Avalere Health, told Bloomberg BNA May 23.

“The budget reflects congressional action to repeal and replace the Affordable Care Act, so the budget assumes the ACA is repealed and replaced along the lines of what Congress is debating,” Carpenter said.

IPAB

The president’s proposed budget also assumes the 15-member Medicare cost-cutting panel, the Independent Payment Advisory Board (IPAB), will be repealed in coming years. Repeal of the group would add roughly $7 billion in federal spending, according to the budget proposal.

Repealing IPAB, which was created under the Affordable Care Act, is a long-standing Republican priority, and the administration hopes to work with Congress to end the cost-cutting mechanism, a spokesperson for the White House told Bloomberg BNA May 23.

The ACA requires IPAB to convene and make recommendations for cutting Medicare spending if the growth in Medicare spending reaches a certain threshold.

IPAB is supposed to be appointed by the president and has broad authority to propose cuts to payments made through Medicare. Congress, which has typically controlled many aspects of Medicare’s payments through legislation, has limited oversight of IPAB, which was set up specifically to make reductions to U.S. health spending at a distance from lawmakers and lobbyists.

The suggestion to repeal IPAB was supported by the Biotechnology Innovation Organization, a trade association for drugmakers.

IPAB is expected to be triggered later this year by the uptick in Medicare spending.

State Health Insurance Assistance Program

The budget would eliminate $52 million for states and territories to counsel beneficiaries on Medicare options.

The money is for the 27-year-old State Health Insurance Assistance Program. The Administration for Community Living in April said it awarded 54 one-year grants, ranging from Guam’s nearly $41,000 to California’s $5 million grant.

SHIPs assist beneficiaries in obtaining coverage through fee-for-service Medicare, Medicare Advantage, and Part D prescription drug plans.

Alternative sources can be found “for Medicare beneficiaries to obtain access to reliable information to better understand and manage benefits,” the budget said.

The Medicare Rights Center, a beneficiary advocacy group, urged Congress to reject ending the SHIP program.

”This seemingly minor, pernicious cut strikes at the heart of the program, leaving people who need help understanding their Medicare with nowhere to turn,” the center said in a statement. SHIPs help people choose how to receive their Medicare benefits, manage denials and appeals, and solve billing disputes, the center said.

About 3.5 million beneficiaries are helped each year through “intensive, personalized” 50-minute sessions, Stacy Sanders, federal policy director for the center, told Bloomberg BNA.

The program has its champions in Congress in part because SHIP counselors can provide case work support to lawmakers’ offices for problems faced by their beneficiary constituents, Sanders said.

Cost-Sharing Reductions

The budget includes $6.3 billion for advanced cost-sharing reduction subsidies for fiscal 2018, payments that would be made to health insurers to cover deductibles and other out-of-pocket expenses for low-income Obamacare enrollees. The 2017 estimate for the subsidies is $5.8 billion.

The cost-sharing reductions have been the subject of a lawsuit filed by the House of Representatives against the Obama administration for funding the subsidies without a congressional appropriation. A federal district court ruled in favor of the House in 2016, and the Trump administration May 22 asked a federal appeals court for a delay so that it could seek a resolution to the lawsuit.

Insurers and other health-care stakeholders have called for certain funding of the subsidies. Insurers say they need certain funding in order to decide whether to participate in the exchanges in 2018. Without the subsidies, they have said they need premium increases of 20 percent just to cover the cost of the subsidies, in addition to other premium increases.

Early premium requests are in the double-digit range following average premium increases of 25 percent in 2017 for the most popular silver tier plans, which cover an average of 70 percent of medical claims.

The budget also includes $32.1 billion for premium assistance tax credits for fiscal 2018, up from about $30 billion for fiscal 2017.

The Affordable Care Act’s basic health program for low-income people would receive $4.5 billion for fiscal 2018, up from $4.4 billion for fiscal 2017.

—With assistance from Sara Hansard and Mindy Yochelson

To contact the reporter on this story: Alex Ruoff in Washington at aruoff@bna.com

To contact the editor responsible for this story: Brian Broderick at bbroderick@bna.com

For More Information

The budget request is at http://src.bna.com/o8s.

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