U.S. House Republicans’ plan to replace the Affordable Care Act was attacked from all sides Tuesday, including criticism by conservative Maine Gov. Paul LePage and U.S. Sen. Susan Collins of Maine, a moderate Republican.

Collins told the Portland Press Herald in an interview Tuesday night that she is “concerned” that the bill’s phase-out of Medicaid expansion would take away health insurance for millions, while LePage assailed it by arguing that the plan does not adhere to “conservative, free-market” principles.

Eliminating Medicaid expansion after 2020 “is a considerable concern of mine,” said Collins, who also expressed strong reservations about the bill’s provision to defund Planned Parenthood.

With Republicans holding a slim 52-48 margin in the Senate, Collins holds a key vote that could determine whether an ACA replacement succeeds or fails.

While not explicitly saying whether she would support or oppose the bill, Collins said she would like to see more people, not fewer, covered by health insurance.

“I want to see the bill improved,” Collins said. She said the House bill is better than an earlier version leaked to the media last week, and she hopes it continues to improve.

“I’m still going through it,” she said. “My goal is to expand access to health care and have more individuals covered than in the ACA, and prevent the collapse of the ACA marketplace.”

Standard and Poor’s Global Ratings on Tuesday estimated that between 6 million and 10 million people would lose coverage under the plan touted by House Speaker Paul Ryan, R-Wisconsin, and endorsed by President Trump. About 20 million Americans have insurance through the Affordable Care Act’s individual marketplace or through Medicaid expansion.

According to an analysis by the Center for American Progress, a left-leaning think tank in Washington, D.C., average out-of-pocket costs for enrollees would increase by $1,500 under the House plan, and by $5,500 for those in the 55-64 age bracket.

Rep. Chellie Pingree, D-1st District, described it as “Robin Hood in reverse” and said the bill is going to be “much worse for people who are older and sicker. If you’ve already got plenty of money to pay for health care, it’s going to be even easier for you to pay for your health care.”

While media reports Tuesday indicated congressional Republicans intend to fast-track the House bill, Collins said replacing the ACA needs to be a slow, deliberative process.

“We need to do this carefully,” she said. “I don’t think we should be rushing this process.”

Collins serves on the Health, Education, Labor and Pensions Committee, one of the panels that would consider the bill if it were to pass the House.

Collins and Sen. Bill Cassidy, R-Louisiana, proposed a replacement bill in January that was considered a centrist alternative to the ACA, and to the left of the Ryan plan unveiled Monday evening. On Tuesday, Collins was hoping the Cassidy-Collins bill could emerge as a compromise ACA replacement.

PLANNED PARENTHOOD TARGETED

She also took a stand against the Ryan-backed bill’s provision to defund Planned Parenthood. In 2015, Collins voted against an ACA repeal because it also would have defunded the organization. While Planned Parenthood performs abortions – making it a target for conservatives – it provides many other health care services for women. Federal money can’t be used to fund abortions, but it does help pay for other health services at Planned Parenthood.

“I do not think defunding of Planned Parenthood is wise from a policy perspective. It has no connection to the ACA, and thus should not be part of the bill,” Collins said.

Planned Parenthood, which would lose all federal funding under the Republican proposal, argued that defunding would lead to the complete loss of health care for those who rely on the organization’s services.

“For many patients, blocking access to Planned Parenthood, to their health care providers, means blocking access to their only access to care. Without Planned Parenthood, they will have nowhere else to go,” said Nicole Clegg, vice president of public policy for Planned Parenthood of Northern New England.

LEPAGE DISLIKES MEDICAID PROVISION

Meanwhile, conservatives like LePage attacked the Ryan bill for keeping some of the Affordable Care Act’s provisions, including retaining Medicaid expansion until 2020.

LePage, in a letter sent to Ryan on Tuesday, said he strongly opposed Medicaid expansion – he has vetoed it five times – because it encourages dependency on government programs.

“It appears congressional Republicans are still intent on catering to big-government lobbyists and politicians in states that took Obamacare’s welfare-expansion bait,” LePage wrote in the letter.

Maine is one of 19 states that did not expand Medicaid, but a referendum is scheduled to go on the November ballot asking Mainers if they want to expand Medicaid under the ACA.

Collins said she agreed with most of the sentiments in a letter sent Tuesday to Senate Majority Leader Mitch McConnell by Republican Sens. Rob Portman of Ohio, Shelley Moore Capito of West Virginia, Cory Gardner of Colorado and Lisa Murkowski of Alaska. The letter said the four signers would “not support a plan that does not include stability for Medicaid expansion populations or flexibility for states.”

Collins said she was not asked to sign the letter because Maine has not expanded Medicaid, while the four states represented in the letter have.

Maine health care experts said the Ryan-backed bill would strip coverage from millions while increasing out-of-pocket health care costs for working-class and middle-class patients – especially hitting the oldest and sickest patients – while at the same time cutting taxes for the wealthy.

The Ryan plan would eliminate Medicaid expansion starting in 2020 and would transform the current system of subsidized insurance purchased on the individual marketplace to a tax credits-based system.

ACA individual market coverage is available for those who can’t get coverage through an employer. Subsidies are provided for those earning up to 400 percent of the federal poverty limit. About 80,000 Mainers have insurance through the Affordable Care Act.

ENDING THE INDIVIDUAL MANDATE

Mitchell Stein, a Maine-based independent health policy consultant and insurance industry expert, said that the plan would destabilize and possibly collapse the health insurance individual marketplace. By eliminating the individual mandate under the ACA that requires people to purchase insurance or pay a penalty, there’s not much incentive for young, healthy people to purchase insurance.

“This is the worst of all possible worlds, and will lead to the proverbial ‘death spiral,’ ” Stein said.

Emily Brostek, executive director of Consumers for Affordable Health Care, an Augusta health policy nonprofit, said the Republican plan would result in millions of people losing their insurance, and for older, sicker and less wealthy patients, premiums would skyrocket.

“This is going to really hurt people who are not young and healthy,” Brostek said. “A 55-year-old Aroostook County resident making $40,000 per year currently receives a $7,500 subsidy to pay for insurance. Under the House plan, they would only get $3,500 in assistance.”

Brostek said that calculation doesn’t even adjust for age under the House plan, which allows insurers to charge higher premiums for older adults than the ACA permits.

The House plan would permit insurance companies to charge older people premiums that are up to five times what a young, healthy person would pay. Under the ACA, insurance companies are only allowed to charge older people three times as much.

Considering that Maine is the oldest state in the nation, Sen. Collins is concerned about creating a system that spikes costs for people who are older and just under 65, the age eligibility for Medicare.

“I have a particular concern about the impact on seniors,” she said.

Topher Spiro, vice president of health policy at the Center for American Progress, said the plan would destabilize the insurance markets and be “horrible” for patients.

“It’s a transfer in health insurance coverage from the poor to the wealthy, from the sick to the healthy and from the old to the young,” Spiro said. “It is not a plan that provides insurance to those who need it the most.”

SHRINKING POOL, HIGHER COSTS

Kevin Lewis, president and CEO of Community Health Options, a Maine-based insurance cooperative created under the ACA, said the House plan would make the pool of insured patients sicker and older, likely driving costs up.

“The lower subsidies will translate into lower participation,” Lewis said. Community Health Options has about 46,000 enrollees.

Lewis said the House plan eliminates the cost-sharing subsidies that help pay for health for those earning between 100 percent and 250 percent of the federal poverty level, up to $60,750 for a family of four. Lewis said the subsidies, which help pay for deductibles, prescriptions and co-insurance costs, help people in lower income brackets use their insurance. If they use their insurance, that means they obtain more preventive care.

“Reducing the financial barriers to improve access for patients benefits everyone,” he said.

The Maine Hospital Association also came out against the proposal Tuesday.

“I don’t see much good in this bill,” said Steven Michaud, the association’s president.

Michaud said hospitals absorbed cuts to Medicare under the theory that with more people insured, revenues to hospitals would increase. But when Maine spurned Medicaid expansion, that cut off substantial revenue to hospitals, and the proposed Republican plan would result in far fewer people with insurance. That will likely result in more uninsured people receiving care from hospitals, driving up their costs, Michaud said.

Rep. Bruce Poliquin, R-2nd District, hailed the proposal as “much-needed health insurance relief.”

“Tens of thousands of Mainers are suffocating under the spiking Obamacare monthly premiums, co-pays and deductibles while other health insurance options continue to shrink. Congress must act to fix this,” Poliquin said in a news release. “This legislation will retain coverage for those with pre-existing health conditions; make sure insurance companies sell health insurance to everyone who wants it; and offer to keep young adults on their parents’ policies until age 26.”

LePage, in a radio appearance Tuesday, said he planned to return later this week to Washington – where he spent the past two weeks – to lobby Republican lawmakers on a replacement for Obamacare.

LePage told talk radio host Ric Tyler at WVOM in Bangor that the replacement plan proposed by House Republicans isn’t an improvement and won’t serve Maine well.

“I’m very, very discouraged and disappointed with what the House Republicans are introducing,” LePage said. “Based on what I see and what I’m reading and what has happened in Maine over the last 15 years, I don’t think it’s an improvement. I think they are punting the ball is what they are doing.”

SEN. KING DISCOURAGED

Sen. Angus King, an independent, also criticized the House replacement plan.

“At first glance, I’m very discouraged by this proposal,” he said in a written statement. “Although the bill maintains some important protections – ones that were first implemented by the Affordable Care Act, I might add – it would more than likely force Maine seniors and low-income folks to pay higher costs and ultimately would result in more people being uninsured than we have now. That’s not health care reform, and it’s certainly not what President Trump promised when he said that the bill would offer affordable coverage for everyone.

“As I have said all along, we should offer meaningful improvements to the Affordable Care Act – not tear it down and jeopardize health insurance for tens of thousands of people in Maine.”

Collins said something needs to be done to improve the ACA, which she said is “collapsing” in many states.

“The current ACA system is under considerable stress,” Collins said. “Those who argue we should do nothing are mistaken.”

Joe Lawlor can be contacted at 791-6376 or at:

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