Jew World Order

Policy Changes

Medicaid Expansion: Ends the enhanced (i.e., 90-95%) federal Medicaid match for all states that have not expanded their Medicaid programs as of March 1, 2017. Any state that has not expanded Medicaid to able-bodied adults after that date could do so however, that state would only receive the traditional (50-83%) federal match for their expansion population. However, the amendment prohibits any state from expanding to able-bodied adults with incomes over 133% of the federal poverty level (FPL) effective December 31, 2017. With respect to those states that have expanded, continues the enhanced match through December 31, 2019, with states receiving the enhanced match for all beneficiaries enrolled as of that date as long as those beneficiaries remain continuously enrolled in Medicaid. Some conservatives may be concerned that this change, while helpful, does not eliminate the perverse incentive that current expansion states have to sign up as many beneficiaries as possible over the next nearly three years, to receive the higher federal match rate. Work Requirements: Permits (but does not require) states to, beginning October 1, 2017, impose work requirements on non-disabled, non-elderly, non-pregnant beneficiaries. States can determine the length of time for such work requirements. Provides a 5 percentage point increase in the federal match for state expenses attributable to activities implementing the work requirements. States may not impose requirements on pregnant women (through 60 days after birth); children under age 19; the sole parent of a child under age 6, or sole parent or caretaker of a child with disabilities; or a married individual or head of household under age 20 who maintains satisfactory attendance at secondary school or equivalent, or participates in vocational education. Medicaid Per Capita Caps: Increases the inflation measure for Medicaid per capita caps for elderly, blind, and disabled beneficiaries from CPI-medical to CPI-medical plus one percentage point. The inflation measure for all other enrollees (e.g., children, expansion enrollees, etc.) would remain at CPI-medical. Medicaid New York Fix: Reduces the federal Medicaid match for states that require their political subdivisions to contribute to the costs of the state Medicaid program. Per various press reports, this provision was inserted at the behest of certain upstate New York congressmen, who take issue with the states current policy of requiring some counties to contribute towards the states share of Medicaid spending. Some conservatives may be concerned that this provision represents a parochial earmark, and question its inclusion in the bill. Medicaid Block Grant: Provides states with the option to select a block grant for their Medicaid program, which shall run over a 10-year period. Block grants would apply to adults and children ONLY; they would not apply with respect to the elderly, blind, and disabled population, or to the Obamacare expansion population (i.e., able-bodied adults). Requires states to apply for a block grant, listing the ways in which they shall deliver care, which must include 1) hospital care; 2) surgical care and treatment; 3) medical care and treatment; 4) obstetrical and prenatal care and treatment; 5) prescription drugs, medicines, and prosthetics; 6) other medical supplies; and 7) health care for children. The application will be deemed approved within 30 days unless it is incomplete or not actuarially sound. Bases the first year of the block grant based on a states federal Medicaid match rate, its enrollment in the prior year, and per beneficiary spending. Increases the block grant every year with CPI inflation, but does not adjust based on growing (or decreasing) enrollment. Permits states to roll over block grant funds from year to year. Some conservatives, noting the less generous inflation measure for block grants compared to per capita caps (CPI inflation for the former, CPI-medical inflation for the latter), and the limits on the beneficiary populations covered by the block grant under the amendment, may question whether any states will embrace the block grant proposal as currently constructed. Implementation Fund: Creates a $1 billion fund within the Department of Health and Human Services to implement the Medicaid reforms, the Stability Fund, the modifications to Obamacares subsidy regime (for 2018 and 2019), and the new subsidy regime (for 2020 and following years). Some conservatives may be concerned that this money represents a slush fund created outside the regular appropriations process at the disposal of the executive branch. Repeal of Obamacare Tax Increases: Accelerates repeal of Obamacares tax increases from January 2018 to January 2017, including:

• Cadillac tax on high-cost health plans not repealed fully, but will not go into effect until 2026, one year later than in the base bill;
• Restrictions on use of Health Savings Accounts and Flexible Spending Arrangements to pay for over-the-counter medications;
• Increased penalties on non-health care uses of Health Savings Account dollars;
• Limits on Flexible Spending Arrangement contributions;
• Medical device tax;
• Elimination of deduction for employers who receive a subsidy from Medicare for offering retiree prescription drug coverage;
• Limitation on medical expenses as an itemized deduction this provision actually reduces the limitation below prior law (Obamacare raised the threshold from expenses in excess of 7.5% of adjusted gross income to 10%, whereas the amendment lowers that threshold to 5.8%);
• Medicare tax on high-income individuals;
• Tax on pharmaceuticals;
• Health insurer tax;
• Tax on tanning services;
• Limitation on deductibility of salaries to insurance industry executives; and
• Net investment tax.

Technical Changes

Retroactive Eligibility: Strikes Section 114(c), which required Medicaid applicants to provide verification of citizenship or immigration status prior to becoming presumptively eligible for benefits during the application process. The section was likely stricken for procedural reasons to avoid potentially fatal points-of-order, for imposing new programmatic requirements outside the scope of the Finance Committees jurisdiction and/or related to Title II of the Social Security Act. Safety Net Funding: Makes changes to the new pool of safety net funding for non-expansion states, tying funding to fiscal years instead of calendar years 2018 through 2022. Medicaid Per Capita Cap: Makes changes to cap formula, to clarify that all non-Disproportionate Share Hospital (DSH) supplemental payments are accounted for and attributable to beneficiaries for purposes of calculating the per capita cap amounts. Stability Fund: Makes technical changes to calculating relative uninsured rates under formula for allocating Patient and State Stability Fund grant amounts. Continuous Coverage: Strikes language requiring 30 percent surcharge for lack of continuous coverage in the small group market, leaving the provision to apply to the individual market only. With respect to the small group market, prior law HIPAA continuation coverage provisions would still apply. Re-Write of Tax Credit: Re-writes the new tax credit entitlement as part of Section 36B of the Internal Revenue Code the portion currently being used for Obamacares premium subsidies. In effect, the bill replaces the existing premium subsidies (i.e., Obamacares refundable tax credits) with the new subsidies (i.e., House Republicans refundable tax credits), effective January 1, 2020. The amendment was likely added for procedural reasons, attempting to bootstrap on to the eligibility verification regime already in place under Obamacare. Creating a new verification regime could 1) exceed the Senate Finance Committees jurisdiction and 2) require new programmatic authority relating to Title II of the Social Security Act both of which would create a point-of-order fatal to the entire bill in the Senate. In addition, with respect to the firewall that is, the individuals who do NOT qualify for the credit based on other forms of health coverage the amendment utilizes a definition of health insurance coverage present in the Internal Revenue Code. By using a definition of health coverage included within the Senate Finance Committees jurisdiction, the amendment attempts to avoid exceeding the Finance Committees remit, which would subject the bill to a potentially fatal point of order in the Senate. However, in so doing, this ostensibly technical change restricts veterans access to the tax credit. The prior language in the bill as introduced (pages 97-98) allowed veterans eligible for, but not enrolled in, coverage through the Veterans Administration to receive the credit. The revised language states only that individuals eligible for other forms of coverage including Medicaid, Medicare, SCHIP, and Veterans Administration coverage may not qualify for the credit. Thus, with respect to veterans coverage in particular, the managers package is more restrictive than the bill as introduced, as veterans eligible for but not enrolled in VA coverage cannot qualify for credits. Finally, the amendment removes language allowing leftover credit funds to be deposited into individuals health savings accounts because language in the base bill permitting such a move raised concerns among some conservatives that those taxpayer dollars could be used to fund abortions in enrollees HSAs.