December 28, 2017

A Year-end Update on Healthcare and Family Caregiving Developments from Contributing Editor Alan Kaplan
It may take weeks, even months for complete comprehension of the intricate provisions of the 500-page tax bill that has now become the law of the land. But, after a year of Perils-of-Pauline legislative events regarding, first, the future of Obamacare, and then the tax package’s effect on healthcare in America, some major takeaways emerge in the following.
The Tax Bill Takeaways
Obamacare, while wounded, also remains, in large part, the law of the land. Although shorn of its individual mandate as of January 1, 2019, the ACA’s Medicaid expansion, quality improvement projects, and marketplace subsidies for income-qualified enrollees have, for now, survived the Republican onslaught of 2017.
  • In fact, as late December enrollment results indicated, the 2017 Obamacare exchange sign-up season had clearly done more than just survive. “More than 8.8 million Americans,” the Washington Post’s Amy Goldstein reported, “signed up for Affordable Care Act health plans for 2018 in the 39 states relying on the federal website, an unexpectedly robust turnout that approaches the 2017 total, despite an enrollment season cut by half and other moves by the Trump Administration to undermine the law’s insurance marketplaces. The numbers the administration reported include an all-time high for the number of new consumers signing up in a single week, with 1 million such people picking health plans in the final days before the December 15 federal deadline.” Furthermore, as the Associated Press reported, “Americans in states the president carried in his march to the White House accounted for more than four in five of those signed up for coverage under the health care law the president still wants to take down. ‘There’s politics, and then there’s taking care of yourself and your family,’ said analyst Chris Sloan of the consulting firm Avalere Health. ‘You can have political views about a program like the Affordable Care Act, but when you get an opportunity to get subsidized health insurance for you and your family, politics is a distant consideration.’”
  • Avoiding disappearance in the tax overhaul was the medical expense deduction, which has afforded families with large medical and caregiving costs some financial relief. The final version of the deduction actually provides a one-year increase in its value inasmuch as the threshold for its use dropped from 10% to 7.5% of adjusted gross income in 2018 (before returning to the 10% level thereafter).
  • The immediate threat to Medicare funding—the pay-as-you-go law’s required $25 billion cut in 2018—has been removed by virtue of a waiver signed by Pres. Trump, part of the short-term federal spending extension enacted along with the tax measure.
  • The prognosis for healthcare legislation in the New Year remains murky. On the one hand, for Sen. Lindsey Graham, the past is prologue: In a year-end tweet quoted in the Washington Post, Graham reiterated his intention to have another go at Obamacare; “To those who believe—including Senate Republican leadership—that in 2018 there will not be another effort to repeal and replace Obamacare—well, you are sadly mistaken.” On the other hand, Graham’s Republican Senate leader Mitch McConnell strongly hinted that “we’ll probably move on to other issues.” And, in another Post article, he “threw cold water” on the efforts of House Speaker Paul Ryan and other conservatives trying to build momentum for reining in spending on Medicare, Medicaid, and other safety-net programs. “I don’t think, as a practical matter in the Senate, we can do entitlement reform without bipartisan agreement,” McConnell said. “And you can fill in the blanks. I mean, it applies to entitlements in general—Medicare, Social Security, welfare—I’m not going to devote more time to something that has no Democratic support.”
  • Left hanging at the Congressional session’s year-end finale was the fate of market stabilization measures advanced by Sen. Susan Collins and Lamar Alexander. The Senators agreed to rely on Sen. McConnell’s assurance that insurers’ cost savings subsidies and state reinsurance programs would see the light of day in 2018’s second congressional session.
Passage of the RAISE Act in Senate
A bit of positive legislative news in 2017 was the growing support for passage of the RAISE Act, which would establish a framework for advancing a national family caregiving strategy. With overwhelming bipartisan support the measure cleared the Senate and seemed well on its way to final enactment in 2018.
Medicaid and Health Delivery Reform Scrutiny
As reported by Caregiving Policy Digest in 2017, not all of the important developments affecting family caregiving flowed from Capitol Hill and White House struggles over healthcare insurance coverage. In particular, the future direction of Medicaid and the fate of numerous health delivery reform initiatives came under intense scrutiny by CMS officials, patient advocates, the provider industry, and the health policy community. Newly installed CMS Administrator Seema Varma spearheaded much of the debate with her pronouncements on state Medicaid waiver criteria, the scope of provider regulatory requirements, and the future direction of efforts to curb healthcare expenditures and increase the value and quality of healthcare services.  
Challenges to Healthcare Initiatives
Research results reported in the medical literature posed some challenges to major initiatives such as the Medicare Hospital Readmission Reduction Program and pay-for-performance approaches. At the same time, the research and resources literature continued to offer ongoing, emphatic documentation of the immense financial and emotional challenges entailed in confronting the needs of individuals needing care and their caregivers—as well as the opportunities for intervention aimed at lessening their burdens.
Nursing Home and Patient Protection Lapses Gaining Attention
Certain to receive heightened attention in the New Year are the state of nursing home quality and patient protection. The last months of 2017 saw numerous press reports detailing alarming lapses in oversight and a growing incidence of patient abuse and neglect.
Patient and Family Advocacy: Successes and Defeat
Looking back on one of the most turbulent years in recent history with respect to healthcare policymaking, two observations seem compelling. First, patient advocacy and family advocacy efforts worked. While not achieving complete success, the unprecedented and coordinated mobilization by patient protection organizations contributed mightily to forestalling the reversal of health care coverage gains made by many previously uninsured Americans.

Second, the one major patient advocacy defeat—the repeal of the individual mandate—could be said to embody the central issue for U.S. citizens and their elected representatives as they continue to wrestle with the kind of healthcare system they owe themselves and each other: what measure of responsibility—individual and/or collective—the nation should pursue. And that brings one back to what arguably was the year’s most evocative and insightful health policy article : Atul Gawande’s meditation on healthcare delivery in the Ohio city of his birth and whether Americans have a “right to healthcare.” His concluding observations bear repeating: “Our willingness to trust in efforts like health reform can be built on experience, though we must recognize how tenuous the trust remains. Two sets of values are in tension. We want to reward work, ingenuity, self-reliance. And we want to protect the weak and vulnerable—not least because, over time, we all become the weak and vulnerable, unable to get by without the help of others. Finding the balance is not a matter of achieving policy perfection; whatever program we devise, some people will put in more and some will take out more. Progress ultimately depends on whether we can build and sustain the belief that collective action generally results in collective benefit. No policy will be possible otherwise.”
There’s still time before year’s end to join us in celebrating our 40th Anniversary. Help us be there for caregiving families and friends when they need it most, with empathy, valuable resources, and practical, immediately useful information.

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Contributing to Caregiving Policy Digest are Alan K. Kaplan, attorney and health policy consultant, Kathleen Kelly, and Francesca Pera (editing and layout).

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