On behalf of the March of Dimes, a unique collaboration of scientists, clinicians, parents, members of the business community, and other volunteers representing every state, the District of Columbia and Puerto Rico, I appreciate this opportunity to submit testimony for the record of the hearing to consider the Graham-Cassidy-Heller-Johnson health care proposal.
I will be blunt: this legislation poses a dire threat to the health of women, infants and families across our nation and should be rejected outright by every Senator.
In particular, the Graham-Cassidy-Heller-Johnson bill poses a special danger to pregnant women and infants, some of the most vulnerable populations. At every turn, this proposal rejects approaches that would make it easier for women and families to obtain affordable, comprehensive care, instead erecting barriers to coverage and removing critical consumer protections.
The March of Dimes is particularly concerned about the impact of this proposal in three areas: Medicaid, the individual insurance market, and state health care systems.
Medicaid Impacts Would Be Devastating
Each year, approximately half of all births in the U.S. are covered by Medicaid.[i] Millions of pregnant women receive comprehensive prenatal care under Medicaid, and their infants are covered for hospitalization, vital well child care, and illness. Medicaid also covers a disproportionate share of high-risk births.[ii] In many states, Medicaid provides crucial wrap-around services for families who have private coverage, but whose children face major health crises with catastrophic costs. For millions of families, Medicaid can make the difference between a healthy or sick pregnancy or baby, and serves as a bulwark against financial ruin for families of medically complex children.
Under the Graham-Cassidy-Heller-Johnson bill, states would lose the ability to cover additional populations under Medicaid, as permitted under the Affordable Care Act (ACA). The March of Dimes estimates that this rollback alone would result in up to 6.5 million women of childbearing age losing coverage,[iii] denying them the opportunity to get healthy before they get pregnant. Many of these low-income women would have no recourse for obtaining coverage or health care.
The bill would also convert the existing Medicaid program from an entitlement program to a combined block grant and per capita cap funding structure, potentially wiping out the current requirements that states cover certain mandatory populations, such as pregnant women and children. In addition to these likely coverage losses, the conversion of Medicaid from an entitlement to a capped system is expected to eliminate numerous patient protections in the name of state flexibility. For example, states might no longer be required to adhere to the Early Periodic Screening, Diagnostic and Treatment (ESPDT) standard of providing medically necessary care to children.
Finally, the Graham-Cassidy-Heller-Johnson bill is estimated to reduce federal funding Medicaid by over $713 billion through 2026 alone[iv]. It is simply impossible to drain this degree of resources from our health care system without extensive consequences for patients, providers, and other stakeholders. States will be forced to serve fewer people, offer fewer services, cut payments to doctors and hospitals, raise taxes, or some combination of all of these measures.
The Individual Market Would Revert to Only Serving the Healthy
Under the Graham-Cassidy-Heller-Johnson proposal, the Affordable Care Act’s provisions around Marketplaces would be eliminated and states would receive funds to establish their own systems. In the name of flexibility, states would be allowed to permit insurers to charge sick people higher rates, not cover essential health benefits, and impose caps on services and benefit levels.
In a nutshell, this bill would return us to the days when only healthy people could afford coverage in the individual market. Allowing insurance companies to engage in medical underwriting again will almost certainly set off a “race to the bottom,” where insurers compete for the healthiest customers by offering cheap plans that cover few services. Lower premiums may be achieved, but they will only be available to a limited population, and the plans with lower premiums may not cover the services people actually need. Prior to passage of the ACA, only 13% of plans in the individual market covered pregnancy[v]; in most cases, women who needed this coverage had to purchase costly riders, or could not obtain maternity coverage at all. Numerous analysts have noted that maternity and newborn coverage will likely be among the first benefits insurers will choose to exclude from plans.
Among those states that waive the essential health benefits (EHB) requirements, annual and lifetime caps will also make an unwelcome reappearance. Because the ACA’s prohibition on annual and lifetime caps only applies to EHBs, the elimination of the EHB requirement will functionally void the ban on caps. Once again, families will be find themselves in dire straits when a single major illness or chronic condition could render a child uninsurable permanently. In some cases, an infant born extremely preterm or with other serious complications could exhaust her lifetime limit before even leaving the hospital.
States Need Appropriate Time and Investment to Build New Health Systems
The Graham-Cassidy-Heller-Johnson bill envisions each state undertaking the herculean task of building a new individual marketplace system in only two years. While some states may be capable of producing a full-fledged system within this timeframe, many will likely require more time. If states must have functional systems by 2020, it is highly probable that those systems will not adequately address the needs of maternal and child health.
In fact, states are already struggling to serve maternal and child health appropriately. For the past two years, preterm birth rates have increased, after declining for the prior several years.[vi] Maternal mortality rates across the U.S. exceed those in most developed nations.[vii] In many U.S. communities, infant mortality rates rival those of third world countries.[viii] Stark disparities exist among birth outcomes for many racial and ethnic groups. Maternal and child health serves as an exquisitely sensitive barometer for the effectiveness of our health care system, and in too many communities it already indicates serious problems.
Moreover, the Graham-Cassidy-Heller-Johnson bill seems to expect that states will be able to impose cost-containment efforts that the federal government, with its more significant bargaining power and reach, has not. Any serious attempt to restrain costs in our health care system must recognize that the least effective approach is simply to reduce spending. Instead, the government should closely examine the actual drivers of costs and address them directly with targeted interventions. One of the most effective ways to restrain costs would be to engage in sensible, meaningful efforts to promote preventive care. For maternal and child health, this would mean increasing access to well woman, prenatal and well child care to improve outcomes for both mothers and their babies.
States require time, resources, collaboration, and access to best practices in order to construct a health care system that supports healthy pregnancies, babies, and families. The Graham-Cassidy-Heller-Johnson proposal provides none of the tools necessary to make that possible.
Conclusion
Throughout our history, the March of Dimes has advocated for patient-centered systems of care that expand access, improve quality, and reduce costs for all parties in the system with the ultimate goal of healthy pregnancies and healthy babies. Unfortunately, the Graham-Cassidy-Heller-Johnson bill fails on all counts to satisfy these standards. Expecting states to produce dramatically better outcomes with radically fewer resources is little more than magical thinking.
The March of Dimes urges all Senators to oppose the Graham-Cassidy-Heller-Johnson legislation. This bill is bad medicine for pregnant women, children, and families all across our nation.
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[i] Markus AR, Andres E, West KD, Garro N, Pellegrini C. Medicaid covered births, 2008 through 2010, in the context of the implementation of health reform. Women’s Health Issues. 2013;23(5):e273-e280.
[ii] Markus A, Garro N, Krohe S, Gerstein M, Pellegrini C. Examining the Association between Medicaid Coverage and Preterm Births Using 2010-2013 National Vital Statistics Birth Data. Journal of Children and Poverty. 2016;23(1):79-94.
[iii] http://www.marchofdimes.org/news/statement-of-stacey-d-stewart-presiden…;
[iv] http://avalere.com/expertise/managed-care/insights/graham-cassidy-helle…;
[v] http://www.marchofdimes.org/advocacy/affordable-care-is-essential-to-mo…;
[vi] https://www.cdc.gov/nchs/data/vsrr/report002.pdf
[vii] http://www.who.int/reproductivehealth/publications/monitoring/maternal-…;
[viii] https://www.cdc.gov/nchs/data/nvsr/nvsr63/nvsr63_05.pdf