ACA Sabotage

2019 OPEN ENROLLMENT ENDS (most states)

Time: D H M S

A couple of weeks ago, I noted that Iowa had come up with an ingenious plan to resolve their troubled individual health insurance market: Start offering junk plans for everyone and damn the consequences:

Well, sure enough, just yesterday the Iowa state Senate voted to allow unregulated junk plans to be sold to...pretty much anyone in the state:

The Iowa Senate voted Wednesday to let the Iowa Farm Bureau Federation and Wellmark Blue Cross & Blue Shield sell health insurance plans that don't comply with the federal Affordable Care Act.

The new coverage could offer relatively low premiums for young and healthy consumers, but people with pre-existing health problems could once again be charged more or denied coverage.

This morning I took a look at the "Short Term, Limited Duration" policies (aka "Short-Term Plans"). Now comes the other half of Donald Trump's #ShortAssPlans executive order: "Association Plans".

I've obviously already written a bunch of stuff about this, including links to a few impact projection analyses, but this one was put together by Avalere Health on behalf of America's Health Insurance Plans (AHIP), which is one of the two major insurance carrier lobbying groups (the other one is BCBSA). On the surface you may expect a whitewash: "Oh, look at that, a report commissioned by Big Insurance is releasing a report claiming that these policies would be awesomesauce, big surprise!"

However, the actual analysis is quite different than what you might expect:

A few days ago I warned Congressional Democrats that while I agree that appropriating CSR reimbursement payments at this point would be a net negative move thanks to the clever Silver Load/Silver Switcharoo workaround developed last year, there's one possible cloud surrounding that silver lining, so to speak: What if the Trump Administration were to attempt to put the kibosh on Silver Loading altogether?

I don't know the legality of such a move, mind you, but It has been thrown around the rumor mill of late, so I figured I should remind them to keep that possibility in mind.

Well, today I received some reassurance...

Azar Says He Is Not Aware Of Discussions On Blocking ‘Silver-Loading’ in 2019

*(OK, much of it is already here, actually)

Former CMS representative and current healthcare policy advisor for Sen. Brian Schatz, Aisling McDonough, made an important point last night:

If you have a pre-existing condition and live in a rural area, especially in VA, TN, OH, IN, MO, IA, or NV, then I'm worried there might not be a plan available for you next year.

(I pulled those states from this KFF brief: https://t.co/WgCWO16wOa)

— Aisling McDonough (@AislingMcDL) March 12, 2018

People should be worried about bare ACA counties in 2019 b/c of GOP sabotage.

Between mandate repeal, short-term plans, health ministries, farm bureaus, etc, the guaranteed $ for the lone ACA insurer is getting smaller. It's not the same calculus as it was in 2017 & 2018.

— Aisling McDonough (@AislingMcDL) March 12, 2018

UPDATE 4/11/18: I posted this piece about a month ago; I don't have any specifics, but I have reason to believe that the Michigan state legislature could be moving on this any day now. If you live in Michigan, CALL YOUR STATE SENATOR OR REPRESNTATIVE AND TELL THEM *NOT* TO IMPOSE WORK REQUIREMENTS ON "HEALTHY MICHIGAN" ENROLLEES!

h/t to Annette Prentice for the heads up on this. Via Michigan Public Radio:

State Senate introduces bill to add work requirements to Medicaid

The bill would require able-bodied adults to work or be in school for 30 hours a week in order to receive Medicaid.

Some lawmakers in Lansing want people to work to get Medicaid. The Senate introduced a bill Thursday. It would add work requirements to the Medical Assistance Program, or Medicaid.

...If passed, able-bodied adults would be required to work or continue school for 30 hours per week as a condition of receiving medical assistance.

 

(sigh) They. Will. Never. Let. It. Go. Via Kimberly Leonard of the Washington Examiner:

Top Republican looks to codify move to short-term healthcare plans

Sen. John Barrasso, R-Wyo., introduced legislation Wednesday that would let more people enroll in short-term health insurance plans, an idea that builds off a Trump administration proposal issued last month.

The Improving Choices in Health Care Coverage Act would allow people to stay on less expensive, short-term medical plans for as long as 364 days and allow them to renew for subsequent years.

Yes, that's right: "Improving Choices in Health Care Coverage Act", or ICHCCA. I'm going with #IckyJunkPlan instead, it rolls off the tongue better.

In other words, this would codify Donald Trump's executive order into federal law. It might even trump (no pun intended) state laws against #ShortAssPlans, although perhaps not.

*(except people who are actually sick, that is) --h/t Anne Paulson

I've written a lot about Idaho's decision to simply ignore ACA regulations by allowing non-ACA compliant healthcare policies which would destabilize the individual healthcare market even worse than it already is today.

A couple of weeks ago, University of Michigan law professor and ACA expert Nicholas Bagley explained how the bigger danger here is that if this move is allowed to stand, it won't be limited to just Idaho:

But it would be a mistake to ignore what Idaho is up to. If the Trump administration doesn’t intervene, other red states will surely follow in its footsteps. The result will be widespread disregard of the law and the rise of state-to-state inequalities in the private market similar to those that already exist in Medicaid.

In a move which should surprise exactly no one, Congressional Republicans are attempting to defund Planned Parenthood AGAIN:

House Republicans are demanding a series of controversial abortion and health care policies in the annual health spending bill, setting up a showdown with Democrats and threatening passage of an omnibus spending package to keep the government open.

Democrats are vowing to block the slew of long-sought conservative priorities. The riders would cut off federal funding to Planned Parenthood, eliminate a federal family planning program and ax the Teen Pregnancy Prevention Program, according to sources on Capitol Hill. Republicans also want to insert a new prohibition on funding research that uses human fetal tissue obtained after an abortion.

In 2018, unsubsidized premiums for ACA-compliant individual healthcare policies have shot up by around 30% on average nationally. Around 18 points of this (60% of the total) is due specifically to policy decisions by the Trump Administration and Congressional Republicans, primarily the cut-off of Cost Sharing Reduction reimbursement payments and the (accurate, as it would later develop) anticipation, by some carriers, of the ACA's individual mandate being repealed.

What about 2019, however? The 2-3 points tacked on out of concern for the mandate being repealed was only a small portion of the full impact insurance carriers expect it to have, and of course there's the further undermining of the ACA via Donald Trump's "Short Term" and "Association Plan" executive orders. Finally, there's the impact of what is assumed to be another year of the advertising/outreach budget being starved by the Centers for Medicare & Medicaid.

 

Back in June 2016, the Obama Administration rightly clamped down on "Short-Term Plans", limiting them to, you know, a "short term"...no more than 3 months out of the year, while also making them non-renewable; that is, you couldn't get around the 3-month limit by simply renewing the policy every three months:

 

From the Cabinet Meeting scene in the comedy "Dave":

DAVE: Now the Commerce Department..,

SECRETARY OF COMMERCE (sitting erect): Yes, Mr. President?

DAVE (from a card): You're spending forty-seven million dollars on an ad campaign to... (reading) 'Boost consumer confidence in the American auto industry.'

SECRETARY OF COMMERCE: Um...yes, sir...it's designed to bolster individual confidence in a previous domestic automotive purchase.

DAVE: So we're spending forty-seven million dollars so someone can feel better about a car they've already bought?

SECRETARY OF COMMERCE: Yes, sir, but I wouldn't characterize it that way...

DAVE (indignant): Well I'm sure that's really important, but I don't want to tell some eight- year-old kid he's got to sleep in the street because we want people to feel better about their cars. (beat) Do you want to tell him that?

SECRETARY OF COMMERCE (quietly): No sir...(looks at TV cameras)...no sir, I sure don't.

 

Hot Off the Presses, via Kimberly Leonard of the Washington Examiner...

President Trump’s budget plan released Monday endorsed an Obamacare repeal and replace bill that gives funding to states and makes cuts to Medicaid.

...Sens. Lindsey Graham, R-S.C., and Bill Cassidy, R-La., are behind the legislation that takes Obamacare’s funding for the Medicaid expansion and tax subsidies for lower premiums and gives it to states through block grants. The senators introduced the bill in September along with Sens. Ron Johnson, R-Wis., and Dean Heller, R-Nev.

The bill would end the Medicaid expansion under Obamacare but supporters say states can implement it individually if they want. However, the bill makes cuts to Medicaid overall by capping federal funding per beneficiary.

The bill failed to get enough support in Congress in September, as some senators from expansion states worried about Medicaid cuts and protections for people with pre-existing conditions.

(sigh) One More Time, folks...

Last year, in my "If I Ran the Zoo" piece, I stuck my neck out and noted that the single biggest problem with the Individual Mandate isn't that it exists, but that it's not strong enough (conservative healthcare writer Michael Bertaut, who I disagree with on most issues but respect on this topic, also argues that the mandate has never been enforced strongly enough either). Here's what I said at the time:

The reality is that as much as everyone complains about the $695 or 2.5% income individual mandate penalty for NOT having qualifying healthcare coverage, the penalty should really be increased. There, I said it. The problem is that if the penalty is significantly less than the amount that the premiums would be, some people will still decide to eat the tax instead of signing up.

I've been expecting the first and third of these developments:

MARYLAND Open enrollment extended by one week:

OPEN ENROLLMENT EXTENDED UNTIL DEC. 22
ONE WEEK ADDED TO ENROLL IN 2018 HEALTH, DENTAL COVERAGE

BALTIMORE (DEC. 13, 2017) – Open enrollment through Maryland Health Connection has been extended until Friday, Dec. 22 to choose a plan for health coverage to begin Jan. 1, 2018, with expanded call center hours through next week.

Individuals can apply at MarylandHealthConnection.gov or through the “Enroll MHC” mobile app available free in the App Store (iOS) and the Google Play Store (Android).

Also, hundreds of insurance brokers and navigators around the state can help Marylanders apply for financial help and enroll in a plan. Their locations and contact information are available at MarylandHealthConnection.gov or through a GPS-enabled locator tool on the app.

As I noted earlier, the price Maine GOP Senator Susan Collins appears to be demanding is passage of the Alexander-Murray stabilization bill and passage of her own Collins-Nelson reinsurance bill. I addressed Alexander-Murray in my last post, but let's take a look at Collins-Nelson:

Collins' bill with Nelson would set aside $4.5 billion over two years to help states establish reinsurance programs. Reinsurance directly compensates insurance carriers for their most expensive customers.

To the best of my knowledge, that's...pretty much all it does: $2.25 billion per year for two years, and then...that's it. If there's more to the bill than that, I'll revise this post, but in the meantime, that seems to be the whole bill.

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