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A Project of The Annenberg Public Policy Center

Health Care Spin in Tennessee

A Democratic TV ad in the Tennessee Senate race spins the facts on votes that Rep. Marsha Blackburn cast on health care:

  • The ad claims she voted in 2012 “to give members of Congress health care for life.” In fact, lawmakers already had received a health insurance retirement benefit. There was a possibility at the time that lawmakers could have lost the benefit, but that never happened.
  • It also references a vote in 2017 to take “away maternity coverage from women.” Her vote to repeal and replace the Affordable Care Act would have allowed states to set benefit requirements for individual and small-group plans. Some states may have no longer required insurers to offer maternity coverage, but the failed bill wouldn’t have automatically ended the requirement.

The TV ad was launched in early October by Majority Forward, a 501(c)(4) organization that is affiliated with the Democratic super PAC Senate Majority.

Blackburn is running against Democrat Phil Bredesen, a former Tennessee governor.

We’ll take the votes referenced in the ad in chronological order.

Repeal Vote, or ‘Health Care for Life’?

In the ad, a woman named Elizabeth from Williamson County, Tennessee, says: “Congresswoman Blackburn voted to give members of Congress health care for life.” Majority Forward’s support for the ad references a July 2012 vote to repeal the Affordable Care Act. It was not specifically a vote on congressional health benefits, though Democrats spun it that way at the time.

What does the repeal of the ACA have to do with lawmakers’ health care? When the health care legislation was being debated, an amendment by Republican Sen. Chuck Grassley was added to the Senate bill to require that members of Congress and their staffs get insurance coverage through the ACA’s exchanges — for those who buy their own coverage through the individual market — as opposed to continuing to get insurance through the Federal Employees Health Benefits Program.

The idea behind Grassley’s amendment was that if the exchanges were good enough for other Americans, they should be good enough for Congress.

This created some issues, however, for the Office of Personnel Management, which is essentially the human resources department for the federal government. (And it sparked a stream of false claims over the years about Congress being “exempt” from the health care law.)

Federal employees can keep their FEHB coverage once they retire, provided they are eligible to retire and had at least five years of FEHB coverage immediately before retirement, or coverage for the entire period of their service. It’s not free — they would continue to pay part of the premiums, just as they do while working.

But once the ACA was enacted in 2010, it required members of Congress to eventually move to the ACA exchanges, which held the first open enrollment period in late 2013, for plans starting in January 2014. It looked like lawmakers would lose their health insurance retirement benefit.

So, when House Republicans voted to repeal the law in 2012, Democrats made the argument that the vote would reinstate the benefit for Congress.

An anonymous Democratic official told the Hill newspaper at the time: “House Republicans are set to repeal the promise that members of Congress have health care just like everyone else and to restart the perk of lifetime government health care for themselves.”

This talking point, however, has grown stale. The ACA wasn’t repealed, of course. And Congress didn’t lose its retirement benefit, either.

In October 2013, a few months before the ACA exchange coverage would take effect, the Office of Personnel Management issued a final rule saying that lawmakers and their staffs would still be eligible to join the FEHB in retirement, provided they had five years of continuous coverage through either the FEHB or the ACA exchanges, as the Congressional Research Service explained in a 2017 report.

While some Democrats may have cast the repeal vote in 2012 as one that would have reinstated the health care retirement benefit, Republicans were focused on repealing other aspects of the law. Blackburn issued a statement the day of the vote, saying, “Obamacare was a mistake and I’ll keep fighting to repeal it until we get this law off the books. House Republicans remain committed to working step-by-step to replace Obamacare with real solutions.”

And the ad doesn’t mention that eligible lawmakers had this so-called “health care for life” benefit before the ACA and still have it today.

Maternity Coverage

In the ad, Elizabeth says she had an “incredibly complicated” delivery that required a lengthy hospital stay and would have cost about $950,000 without insurance. “I met with Congresswoman Blackburn as they were talking about taking away maternity coverage from women,” she says. “She basically said that there was nothing she could do.”

The reference is to the Republicans’ American Health Care Act — one of the repeal-and-replace efforts in 2017. The House passed it, and Blackburn voted for it. The Senate did not pass it.

The bill wouldn’t have automatically taken away maternity coverage. But it would have allowed states to get waivers to change or waive the 10 essential health benefits requirement of the ACA for individual market and small-group market plans. That means some states could have waived a benefit requirement like maternity coverage for those markets.

The ACA’s 10 essential health benefits are: ambulatory, emergency, hospitalization, maternity and newborn care, mental health and substance use disorder services, prescription drugs, rehabilitative services and devices, laboratory services, preventive care and chronic disease management, and pediatric services including dental and vision.

Before the ACA was enacted in 2010, 18 states offered some protections for maternity coverage in the individual or small-group market, and 11 of those required insurers in the individual market to include coverage of maternity care, according to the Kaiser Family Foundation. Tennessee was not among those states.

A 2012 report from the National Women’s Law Center examined 3,331 individual market policies in state capitals in 48 states and Washington, D.C., and found that just 12 percent of them included maternity coverage. None of the 107 plans in Tennessee included such coverage, though 16 offered a separate maternity rider. Those riders, which function like add-on coverage to the main policy, cost $101.35 to $228.20 per month in the state. The NWLC report notes that riders often included waiting periods as well before they would cover a pregnancy.

We can’t predict whether Tennessee would have waived the maternity coverage requirements if the Republican health care bill had been enacted. But it certainly would have been a possibility. The TV ad would be accurate to say that Blackburn voted for a bill that “would have eliminated guarantee of maternity coverage,” as Majority Forward’s support for the ad says in pointing to a brief on this issue by the Kaiser Family Foundation. A state would have to decide to eliminate the coverage requirement.

In the nonpartisan Congressional Budget Office’s analysis of the legislation, it estimated that about one-third of the U.S. population lives in states that would “make moderate changes to market regulations” under the bill, and about one-sixth lives in states that would request both waivers to change the essential health benefit requirements and to allow pricing based on health status for a limited time for those without continuous coverage.

Average premiums would decrease, CBO explained, in states that reduced or eliminated the benefit requirements, but out-of-pocket expenses for those who used the eliminated benefits would go up. “In particular, out-of-pocket spending on maternity care and mental health and substance abuse services could increase by thousands of dollars in a given year for the nongroup enrollees who would use those services,” CBO said.

To mitigate this issue, the House bill included $15 billion in funding to states to be used for maternity coverage, and mental health and substance abuse treatment. And maternity coverage could be sold as an optional rider, as it was before the ACA. Still, CBO said the cost of the rider would cause “substantially higher out-of-pocket health care costs for pregnant women.” Insurers would “price that rider at close to the average cost of maternity coverage, which could be more than $1,000 per month,” CBO said. Or they could offer a less expensive rider for limited coverage.

Like many aspects of the ACA, the essential health benefits requirement mainly affects the individual market, where 7 percent of Americans get their insurance. Employer plans with 15 or more employees are separately required to cover maternity care under the Pregnancy Discrimination Act of 1978. And even smaller firms have been affected by that law. The Kaiser Family Foundation explained that the Health Insurance Portability and Accountability Act of 1996 broadened the effect of the PDA by forbidding small-group plans, for employers with as few as two employees, from denying coverage to some employees. “This means small employers not subject to the PDA nonetheless had the opportunity to buy policies with maternity benefits sold to larger employers,” KFF said. 

The woman in the ad has a personal stake in this issue. She is Elizabeth Wanczak, who — in addition to meeting with Blackburn in her Franklin, Tennessee, office in April 2017, according to Majority Forward — also attended a town hall meeting hosted by Blackburn in February of that year. The Tennessean quoted Wanczak and reported that she said “she wouldn’t have been able to have her daughter if not for the insurance she found through the federally run health insurance exchange. She came to learn about maternity coverage included in any replacement plan pledged by congressional Republicans.”

Viewers of this ad, however, aren’t getting the whole story on the Republican plan, how it would have worked and who it potentially could have affected.

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Rep. Marsha Blackburn "voted to give members of Congress health care for life."
TV ad
Tuesday, October 2, 2018