I have been getting quite a few alerts on proposed changes happening behind the scenes with the ACA. I also found a couple of new places with some intelligent writers who have explained things in greater depth than what I knew. The CMS is proposing a rule allowing states greater authority in defining the ACA. This comes in addition to Trump’s EO. The new rule would give states greater flexibility in:
– Defining the ACA’s minimum essential benefits to increase affordability of coverage,
– a larger role in the certification of qualified health plans offered on the federal insurance exchange,
– and more leeway in setting medical loss ratios for individual-market plans.
If a state redefines the minimum benefits in the ACA, what we can expect to see is emerging trash plans or mini-plans, which were sold by McDonalds and other companies and are useless in many cases. Granting states a larger role in qualifying healthcare plans on the healthcare exchanges gets back to what I have pointed out before; states failed miserably in defining healthcare requirements and in providing healthcare to citizenry in many cases. Before the ACA, healthcare was the ER due to a lack of insured coverage. Patients were paying Chargemaster rates and often times paid little of the bill due to extremely high bills or low income.
Does the CMS proposal force states to adequately protect the vulnerable as called out in Section 1332 of the ACA? The same as the Senate Bill Alexander-Murray; without a change in Section 1332 of the ACA, underfunded states will have to provide similar coverage. Under Section 1332 States can:
“propose a change or eliminate almost all core ACA features, the individual and employer mandates, plan design including the Essential Health Benefits, and the subsidy basis and schedule. For a waiver to be allowed; however, the state must demonstrate that it will cover as many people, with coverage as affordable and comprehensive as the default structure and must not increase the deficit.”
In other words, the state can get a waiver to the ACA requirements as long as the state can show it covers the same numbers of people with just as affordable and comprehensive state coverage as the ACA while not increasing the deficit (to be redundant in stating such in all three cases). I do not see the CMS getting past this part of the ACA law and Alexander-Murray Republican-Democrat alliance proposes to change Section 1332 and the subsequent 2015 guidance.
In 2015, HHS had issued guidance on Section 1332 of the ACA stating a wavier:
Shall not disadvantage “vulnerable (low income, elderly, disabled), etc. residents.”
“Assessment of whether the proposal covers a comparable number of individuals also takes into account the effects across different groups of state residents, and, in particular, vulnerable residents, including low-income individuals, elderly individuals, and those with serious health issues or who have a greater risk of developing serious health issues. Reducing coverage for these types of vulnerable groups would cause a waiver application to fail this requirement, even if the waiver would provide coverage to a comparable number of residents overall.”
Shall not disadvantage residents by affordability.
(The CSR subsidies President Trump stopped with his Executive order will cause increased 2018 healthcare insurance premiums which will be picked up by premium subsidies for anyone who was eligible for a CSR subsidy. What makes it interesting is how the states apply this increase and their application of it could favorably impact all people who are on the healthcare exchanges [more on this later] ).
“Waivers are evaluated not only based on how they affect affordability on average, but also on how they affect the number of individuals with large health care spending burdens relative to their incomes. Increasing the number of state residents with large health care spending burdens would cause a waiver to fail the affordability requirement, even if the waiver would increase affordability for many other state residents. Assessment of whether the proposal meets the affordability requirement also takes into account the effects across different groups of state residents, and, in particular, vulnerable residents, including low-income individuals, elderly individuals, and those with serious health issues or who have a greater risk of developing serious health issues. Reducing affordability for these types of vulnerable groups would cause a waiver to fail this requirement, even if the waiver maintained affordability in the aggregate.”
The Alexander-Murray bill removes both guiding regulations and substitutes a much weaker one for affordability. Both the Alexander-Murray bill and the CMS proposals surrender control of providing healthcare to states with less federal funding and the same attitude of providing healthcare as experienced in the past. It leaves those who are uninsured or under insured vulnerable to state politics and includes the low-income individuals, elderly individuals, those with serious health issues, and those who have a greater risk of developing serious health issues now protected by the ACA.
While not Medicare-for-all, single payer, or something mimicking European healthcare; the ACA was still a huge step forward in comparison to what existed before it. It eliminated an attitude as expressed by Michigan State Senator Joseph Hune’s upon the passage of the Medicaid expansion; “I am sick to my stomach with the expansion of Medicaid.” An embarrassment of the same magnitude as Trump’s in his public comments and ignorance.
Alexander-Murray also calls for the HHS to issue guidance by providing examples of model state plans that meet the requirements for approval or what has been called cookie-cutter waivers. When asked by one blogger whether Alexander-Murray whether the amendment to Section 1332 effectively protects the vulnerable now protected in the ACA Timothy Jost had this to say:
“If administered by the Obama administration probably yes; if administered by the Trump administration, who knows? (sounds like a “no” to me) I think the intent of the provision is clear, that affordability not be decreased for vulnerable populations; but, the repeal of the guidance and of the procedural rule are to me, the most troubling parts of the bill.”
Given the attitude displayed by this administration now and in many state legislatures pre-ACA, it is hard to believe either would take an approach to protect the vulnerable over providing tax incentives to the 1% of the population making >$500,000 annually and their own re-election in 2018. It is pretty clear what the political priorities are today.
Both Michigan Senators Peters and Stabenow have come out in support of the Alexander-Murray bill repealing the 2015 HHS guidance including the detailed regulations governing waiver submission and assessment issued in 2012. An exception is being made for affordability if approved. I believe it is critical the ACA not be tampered with beyond taking it to the next level of healthcare which might be a form of European and a two tiered system. At this point in time with a lunatic as the president, I have no reason to support a legislature bent on cutting taxes for the 1% of the housholds making >$500,000 annually. That revenue to support such a tax cut will partially come from healthcare cuts.
I have emailed both Senators asking them to withdraw their support of the Alexander-Murray bill with no reply. It is time to go to pen and paper.
“Does the Alexander-Murray bill adequately protect vulnerable groups?” Andrew Sprung, xpostfactoid blog
“CMS to allow states to define essential health benefits” Harris Meyer , Shelby Livingston and Virgil Dickson; Modern Healthcare