Julie Rovner, KFF Health News
President Donald Trump’s “One Big Beautiful” price range reconciliation invoice would make a few of the most sweeping adjustments in well being coverage in years, largely affecting Medicaid and Affordable Care Act plans — with reverberations felt all through the well being care system.
With just a few exceptions, the price range reconciliation course of — which permits the political get together in management to go a invoice with solely 51 votes within the Senate, relatively than the standard 60 — is how practically each main piece of well being laws has handed Congress for the reason that Eighties.
But utilizing reconciliation to constrict relatively than broaden well being protection, because the GOP is making an attempt now? That is uncommon.
One of the best-known applications born by way of reconciliation is the “COBRA” medical health insurance continuation, which permits individuals who go away jobs with employer-provided insurance coverage to maintain it for a time, so long as they pay the total premium.
That is certainly one of dozens of well being provisions tucked into COBRA, or the Consolidated Omnibus Budget Reconciliation Act of 1985. Also included was the Emergency Medical Treatment and Active Labor Act, which requires hospitals that take Medicare to treat or transfer patients with medical emergencies, regardless of their insurance status — a law that’s become a focus of abortion opponents as they seek to limit access to the procedure.
A key reason so much health policy has passed this way has to do with how Congress manages the federal budget. Federal government spending falls into two categories: mandatory, or spending required by existing law, and discretionary, which traditionally is allocated and renewed each year as part of the appropriations process.
Lawmakers use the reconciliation process to make changes to mandatory spending programs — Medicare and Medicaid are among the largest — as well as tax policy. (For complicated political reasons, reconciliation bills cannot touch Social Security, the last prong in the entitlement program trifecta.)
Reconciliation comes into play only if it is needed to reconcile taxes or mandatory spending to comply with the terms Congress sets for itself each year, through the annual budget resolution. This year the GOP’s focus is finding the cash to renew Trump’s expiring tax cuts, which largely benefit wealthier Americans, and boost military and border security spending.
In years when Congress orders a reconciliation bill, health policy almost always plays a major part. Usually, reconciliation instructions call for reductions in payments to health providers under Medicare — which costs the most of the federal health programs.
For much of the 1980s and 1990s, Democrats in Congress quietly used reconciliation to expand eligibility for the Medicaid program, often by cutting more than the budget called for from Medicare. For every $5 cut from Medicare, about $1 would be redirected to provide Medicaid to more low-income people.
But budget reconciliation has also become a convenient way to make policy changes to the nation’s major health programs, as it is usually considered a “must-pass” bill likely to be signed by the president and not subject to filibuster in the Senate.
As a result, all manner of now-familiar health programs were created by budget reconciliation bills, many of which provided health coverage to more Americans.
The 1989 reconciliation bill created a new system for paying doctors who deal with Medicare sufferers, in addition to a brand new federal company to check the price, high quality, and effectiveness of well being care, right this moment generally known as the Agency for Healthcare Research and Quality.
Children’s well being has been a well-liked add-on over time, together with the gradual enlargement of Medicaid protection to extra youngsters primarily based on household earnings. The 1993 reconciliation invoice created the Vaccines for Children program, which ensures the provision and affordability of vaccines nationwide for uninsured and underinsured youngsters. The 1997 reconciliation invoice created the Children’s Health Insurance Program, which right this moment offers insurance coverage to greater than 7 million youngsters.
In reality, the listing of main well being payments of the previous 50 years not handed utilizing price range reconciliation is brief. For occasion, the 2003 Medicare Modernization Act, which added a prescription drug profit to this system for the primary time, attracted simply sufficient bipartisan help to go by itself.
The greatest well being care regulation of latest many years — the Affordable Care Act — didn’t begin out as a reconciliation invoice, but it surely ended up utilizing the method to clear its closing hurdles.
After preliminary passage of the invoice in December 2009, a particular election value Democrats their sixtieth seat within the Senate — and with it, the supermajority they wanted to go the invoice with out Republican votes. In the tip, the 2 chambers used a separate reconciliation measure, the Health Care and Education Reconciliation Act of 2010, to barter a compromise that included the ACA.
HealthBent, a daily function of KFF Health News, affords perception into and evaluation of insurance policies and politics from KFF Health News chief Washington correspondent Julie Rovner, who has lined well being take care of greater than 30 years.
