The House Energy and Commerce Committee Debates ACA Implementation

There was a standing room only crowd of people packed into the Rayburn Building hearing room to attend Thursday’s hearing on PPACA implementation in front of the House of Representatives Energy and Commerce Committee. Witnesses at the hearing included two senior officials at the Department of Health and Human Services—Gary Cohen of the Center for Consumer Information and Insurance Oversight (CCIIO) and Cindy Mann, Deputy Administrator at the Centers for Medicare and Medicaid Services (CMS)—and five officials from state government. The states represented were Louisiana, Wisconsin, Pennsylvania, Maryland and Arkansas.

The hearing had several dramatic moments as representatives from both sides of the aisle fired political jabs at each other, and at the witnesses.

The tensest moment occurred early on, as Vice-Chair Burgess of Texas interrogated CCIIO Director Cohen on whether or not politically sensitive rules and regulations, such as the essential health benefits rule, had been bottled up by the agency in the run-up to November’s election. Citing a New York Times article by Robert Pear, which claimed that several politically sensitive rules had been available as early as August 2012, but not released by CCIIO until after the election, Burgess inquired as to whether these rules had been held up for political reasons. Cohen replied that he was not aware of the article’s sources and that he was not aware that this had occurred.

Democratic representatives hit back at Republicans for attempting to stall the implementation process. Representative Waxman of California criticized Republicans for their tactics in attempting to stall implementation, first through the Supreme Court lawsuit, then by dragging out implementation until after the presidential election. He noted they are now complaining about the lack of guidance from HHS. “Stop the political grandstanding,” Waxman urged. “We have a law that is doing good already; it is going to do so much more if we make it work effectively.” Representative Dingell followed up by criticizing Republican negativity surrounding the health reform law: “I feel like I’m in a room with a bunch of people who are looking at the donut and seeing only the hole… We know that there are grave problems and that this law will make things better.”

Policy Debates

Beneath the political rhetoric, there were a number of interesting policy discussions. Representative Shimkus of Illinois worried that CMS’s proposed 3.5% fee on plans in federally facilitated exchanges would be passed onto consumers, a fear that was echoed by Secretary Greenstein of Louisiana and Secretary Smith of Wisconsin. Secretary Sharfstein of Maryland swatted away concerns that insurers would not participate in the exchanges, noting that their exchange is attracting new insurers to the state.

Representative Cassidy of Louisiana interrogated Sharfstein on the question of affordability as well, worrying that a family just above the federal poverty level (FPL) Medicaid cut-off of 133% would have trouble paying estimated premiums of $600 per month. Sharfstein rebutted by saying that many such families are currently without health insurance of any kind right now and that the law provides subsidies that these families can use to buy insurance. Because of these subsidies, Sharfstein was confident that the law “will increase access to care” and improve the quality of coverage.

Another much debated topic was the fiscal impact of the Medicaid expansions. Greenstein worried that the Medicaid expansion would have disparate effects on the states. He cited a Kaiser Family Foundation-Urban Institute report which revealed that the Medicaid expansion would create winners and losers in terms of which states will benefit financially. The winners, Secretary Greenstein continued, were mostly states from the Northeast, while the losers were mainly Southern states.

Secretary Allison of Arkansas countered this argument, expressing his belief that Medicaid expansion would both save lives and have a positive financial impact in his state. Expressing concern over Arkansas’ large number of low-income, uninsured adults, Allison asserted that “Medicaid saves lives, it improves health and it provides financial protection.” In addition to improving access to care to Arkansas’ uninsured, the Medicaid expansion, according to Allison, would provide overall fiscal benefits to the state. Citing an Urban Institute report from March 2011, he projected that the Medicaid would cost about $900 million per year, but that the expansion would bring savings in the form of higher federal match rates, a reduction in state spending on uncompensated care, and the macro-economic impact of the expansion. All told, Arkansas projects the fiscal benefits to outweigh the fiscal costs of the expansion by $44 million in 2014 and a total of $700 million between now and 2025.

The hearing provided an opportunity for both critics and supports of the ACA to air their concerns about the implementation of health reform. For federal and state officials, it provided an opportunity to provide more detail on their progress and challenges, and also allowed them to educate the public on several key issues.


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