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Last Build Date: Wed, 18 Oct 2017 22:05:41 +0000

 



State Attorneys General Ask Court For Injunction Reversing CSR Payment Halt

Wed, 18 Oct 2017 21:55:00 +0000

On October 18, 2017, the attorneys general of eighteen states and the District of Columbia asked the United States District Court for the Northern District of California for a temporary restraining order and order to show cause why a preliminary injunction should not issue to compel the Trump administration to continue making cost-sharing reduction (CSR) payments until the lawsuit they have filed is resolved. The motion asks the court to make a decision by 4:00 PM tomorow, October 19, as the next cost-sharing reduction payment is due on October 20. The plaintiffs ask for a nationwide injunction as the issue it addresses is nationwide in scope. The motion is supported by a legal memorandum and numerous affidavits. To obtain preliminary relief, a plaintiff “must establish that he is likely to succeed on the merits, that he is likely to suffer irreparable harm in the absence of preliminary relief, that the balance of equities tips in his favor, and that an injunction is in the public interest.” In the Ninth Circuit, where California is located, it is enough to show that serious legal questions are presented if the balance of hardships tips sharply in the plaintiff’s favor. The brief begins by explaining the purpose of the Affordable Care Act’s cost-sharing reductions: making health care affordable to lower-income individuals enrolled in silver marketplace plans by reducing out-of-pocket limits, deductibles, and other cost-sharing. It notes that insurers are required to reduce cost sharing for eligible individuals and that they are doing so to the tune of $7 billion for 2017. The ACA requires the federal government to reimburse insurers for these costs and up until September of 2017—including eight months of the Trump administration—it did so. Only days before the October payment was to be made, and less than three weeks before open enrollment began for 2018, the administration cut off the payments. The states argue that Congress has in fact appropriated funds to cover the cost sharing reduction reimbursement payments. It is undisputed that Congress appropriated in the ACA funds for the premium tax credits and, the states argue, this appropriation covers the CSRs payments as well. They base their argument on the text, structure, and design of the ACA. This argument was rejected by the lower court in the House of Representatives’ lawsuit, but that decision is not binding on any other federal court and the states’ argument has never been ruled on by a federal appellate court. The states further argue that the executive branch’s sudden termination of the CSR payments was “arbitrary and capricious” and thus prohibited by the Administrative Procedures Act. They contend that President Trump has violated his constitutional duty to “take care that the laws be faithfully executed.” The brief quotes liberally from President Trump’s tweets, in which he claimed, “The Democrats ObamaCare is imploding. Massive subsidy payments to their pet insurance companies has stopped. Dems should call me to fix!”; bragged that the ACA “is being dismantled, but in the meantime, premiums & deductibles are way up!” while health insurance stocks plunge because of his Executive action; and boasted that he had “knocked out the CSRs,” pronouncing the ACA “dead,” “finished,” and “gone.” The brief describes the President as “characteristically frank” in detailing his motives for cutting off the payments, which do not rely on legal analysis. The brief describes in detail, with frequent cites to affidavits filed with the brief, the harm that the states and their residents will suffer because of the administration’s decision. These include destabilizing the states’ individual health insurance markets, increasing premiums, decreasing consumer plan choices, and suppressing market participation. The decision will also, the states assert, increase the number of uninsured individuals in the states and thus their uncompensated care costs. The brief notes that the District of Columbia Court [...]



ACA Round-Up: Alexander-Murray And CSR Payments, QHP Quality Ratings, And More

Wed, 18 Oct 2017 16:47:58 +0000

The language of the Alexander/Murray bill is now available. Our post of yesterday, October 17 provides an on the whole accurate description and analysis of the bill. One late addition deserves further discussion, however. As noted in an earlier post, many states have already required or allowed their insurers to increase premiums to account for the shortfalls the insurers will experience for the CSR payment cut off. Rather than require the insurers to refile their rates again, delaying the 2018 open enrollment period, the proposed language would leave the increased rates in place but require insurers to rebate overpayments to their enrollees and to the federal government as appropriate. These rebates could be delivered monthly or in one-time payments; they could be paid after the year, through the ACA’s medical loss ratio rebate provisions, or in some other way. The rebates would be accounted for in determining premium tax credits and in applying the ACA’s medical loss ratio and risk adjustment program requirements. Consumers would be given notice as to how the rebates would work. The ACA’s medical loss ratio provision already provides a channel for recovering excess profits from insurers. It is problematic as an approach to clawing back excess payments by the government because the payments under current law go to consumers rather than to the government; payments are only made if insurers expenses are less than 80 percent of their premium revenue (which might not be true even if insurers receive excess premium tax credits); and rebates are not paid until long after excess profits are received. These provisions were the last of the bill to be worked out in the bill and need further thought. If a rebate program can be designed that will hold consumers and the government harmless and will allow open enrolment to proceed on November 1, 2017, it might be the best solution that can be achieved at this point. It would have been far preferable for Congress to have appropriated the CSR funding months ago, if it thought an appropriation was necessary beyond that found in the ACA, or for the Trump administration to have promised payment of the CSRs unless and until there was a final decision from the highest appellate court that their payment was illegal. Congress and the Trump administration have dug a deep hole to now climb out of. CMS Issues Technical Guidance For Developing QHP Quality Ratings The Affordable Care Act requires HHS to issue a quality rating for each qualified health plan (QHP) offered through an exchange, as well as an enrollee satisfaction survey that will assess enrollee satisfaction with each QHP issued through an exchange with more than 500 enrollees in the prior year. In October of 2017, CMS issued its Quality Rating System and Qualified Health Plan Enrollee Experience Survey 2018 Technical Guidance, which will apply to developing ratings during 2018 for the 2019 open enrollment period The 2018 technical guidance is quite similar to the 2017 system. Changes include: Insurers in Medicaid expansion states in which the expansion population is covered through the exchange (Arkansas) are required to include their QHP Medicaid enrollees in their QRS data submissions; CMS is adding an immunization for adolescents measure to its score and rating calculation but dropping two other measures dealing with aspirin use and diabetes resource use; To arrive at an overall rating, CMS will assign a weighting of two thirds to the clinical quality management summary indicator, and a one sixth rating to each of the enrollee experience and the plan efficiency, affordability, and management summary indicators; CMS intends to display a global rating and three summary ratings on the HealthCare.gov website for all QHPs for 2019; for 2017 and 2018 they were only displayed on a pilot basis in Virginia and Wisconsin; and QHP insurers and web-brokers will be able to display AHP quality ratings for all HealthCare.gov QHPs for 2019 with appropriate disclaimers. Slides Outline Agent And Broker Marketplac[...]



Traveling The Valley Of The Shadow Of Death In 2017

Wed, 18 Oct 2017 12:36:22 +0000

My mother has a letter from her mother written in 1942, telling of the death from pneumonia of a middle-aged neighbor with whom my grandmother had spoken at the post office just a week earlier. For most of human history, that sudden turn to death has been the common experience. Few managed to live into old age; and even for elders, the dying was usually fairly abrupt. There was little risk of living long with dementia, Parkinson’s disease, heart failure, cirrhosis, serious injuries, childbirth complications, or other fatal illnesses. Diabetes was fatal within a few months in 1900. Now, most of us will instead experience a long period of decline in advanced old age. The period of being unable to take care of yourself (mobility, dressing, feeding, toileting) averages more than two years in the last phase of life. During that time, we each will need another person’s help every day—often around the clock. And our society has not even figured out how to talk about the situation, much less how to reorganize to make this newly expectable phase of life comfortable and meaningful, or affordable. US society seems stuck in an era of “happy talk.” When a fireman pulls a child from a swimming pool, it seems appropriate to call it “saving a life.” But how many times have you seen the newspaper headline touting a new drug or device that will “save X thousands of lives,” when, at best, it will delay the dying of very sick and usually elderly people by some months before something else causes death? That may be a good thing, but it is illusory to claim that it is “saving lives.” Advocacy organizations around each eventually fatal illness promote prevention and cure, but none say what would be a better way to come to the end of life. Influential authors tout odd claims such as “Toward a State of Complete Well-Being,” which persuasively argues for investments in prevention and social determinants of health but does not give voice to the limitations imposed by illnesses associated with aging. Public policy falls into the same pattern, with enthusiasm for supporting development of a costly drug that will delay the progression of heart failure, but inattention to issues such as the struggles of family caregivers, the waiting lists for home-delivered meals, and the misfit of available housing with disabilities. My mother now lives through the peculiar torment of progressive disability from frailty in a “care system” that is not designed for her situation: losing nearly half of her weight, barely able to get up from a chair, having a plethora of symptoms with no treatable etiology, and yet having enough heart, lungs, kidney, and liver functions to go on for a while. There will be no letter from a neighbor who is startled when she dies; neighbors will be astonished that she lived so long with such severe disabilities. Hospital care is readily available and paid for, but medications after hours are not available, and she must pay out of pocket for personal care. Hospitals, physicians, pharmacists, and civic leaders have not made plans as to how to serve large numbers of elderly people living in the community with serious and worsening disabilities. Making workable plans would require adopting some novel perspectives and taking account of some salient facts that are often set aside. First, the life possibilities of an elderly person with increasing disabilities is profoundly dependent upon the surrounding community. Is housing accessible? Can you readily get help with minor home repairs, such as changing a light or fixing a gutter? Can you get food delivered, and can you get prepared meals delivered? Can you stay engaged with other people—family, neighbors, and church or club members? Are you considered an embarrassment when out in public with a walker or wheelchair—or an adult diaper? Are walk lights lit long enough for you to cross the street? Are there personal care aides trained to deal with disabilities and challenging behaviors at home, and c[...]



The Alexander-Murray Market Stabilization Package: What’s In It And Where’s It Going?

Wed, 18 Oct 2017 02:55:35 +0000

They may have done it. The apocryphal bipartisan deal to “fix” Obamacare is being struck (at least by two important Senators, for now, in part …). Today, Senators Lamar Alexander of Tennessee and Patty Murray of Washington announced they are converging on an agreement on a short-term package to help stabilize the individual insurance market. Even better, the policies included would likely be somewhat successful in achieving their purported purpose. This post will explore each of them in some detail and consider the impact they may have, as well as the probability Congress will send the legislation to President Trump, who has said he would sign it. The post is based on information about the bill now available, and will likely need to be updated once we see the final language. Funding For Cost-Sharing Subsidies The key component to the deal is stable funding for the cost-sharing reduction (CSR) subsidies that President Trump last week said he would no longer pay. These subsidies lower out-of-pocket costs for individuals enrolled in the Affordable Care Act exchanges with incomes between 100 and 250 percent of the federal poverty level. The legality of the Obama (and then Trump) Administration’s making these payments has been the subject of a legal dispute over whether Congress has actually appropriated the money to fund the requirements of the underlying ACA provisions. Complicating matters further, 19 state attorneys general just filed a lawsuit seeking to compel continued funding of the program. Regardless of the status of the funding, insurers are obligated to furnish eligible enrollees with the discounts. What the President did last week was stop reimbursing plans for the cost of doing that, which equates to higher premiums as insurers then pass through those additional costs to consumers. In fact, the Congressional Budget Office (CBO) estimated that terminating CSR payments would increase premiums by 20 percent in 2018. Further, and importantly for the viability of this bill, they also said eliminating CSRs increases Federal spending – in the form of increased premium subsidies for those facing these higher premiums – by $194 billion over the next 10 years. It would stand to reason then that appropriating these funds would save the government money, but that remains to be confirmed by CBO. Their analysis of the Better Care Reconciliation Act (BCRA) found that extending CSR subsidies would have no impact on Federal spending. If the cost of terminating CSRs equates, even fractionally, to savings for restoring them, the Alexander-Murray deal should be self-funded, with perhaps some extra offset room for must-pass legislation such as extending the Children’s Health Insurance Program (CHIP) or financing state reinsurance programs for the individual market. One potential pitfall for this element, which we understand is the focal point of ongoing negotiations, is the possibility insurers could “double dip” on the CSR funding by receiving these payments and keeping rate increases they had filed under the assumption the policy would be terminated. If insurers are required to refile their rates to avoid double dipping, the administration may need to delay or extend the 2018 open enrollment period, which is only two weeks away. Keep an eye on this one. Changes To Section 1332 Waiver Rules Probably the counterbalancing pole of the package for Republicans is a loosening of criteria for the section 1332 waiver process under the ACA which allows states to alter some of the law’s individual market coverage parameters. Most importantly, it changes the requirement that state proposals be “as affordable as” ACA coverage would be; it requires only that they have “comparable affordability.” Unlike some of the repeal and replace proposals we saw earlier in the year, no changes could be made that would undermine protections for people with preexisting conditions or eliminate essential health benefits. This component of the deal would[...]



Despite Leaving Key Questions Unanswered, New Contraceptive Coverage Exemptions Will Do Clear Harm

Tue, 17 Oct 2017 15:56:21 +0000

On October 6, the Trump administration released an overhaul of federal regulations governing religious objections to the Affordable Care Act’s (ACA) contraceptive coverage guarantee. The move had been long expected. In early May, President Donald Trump issued an executive order on “religious liberty” that signaled his intent to undermine the guarantee; a few weeks later, media outlets published a leaked draft of the new regulations. The two regulations issued on Friday—which took effect immediately—closely match the draft from May by creating sweeping new exemptions from the contraceptive coverage guarantee for employers, schools, individuals, and insurers with religious or moral objections to some or all contraceptive methods and services. Contraceptive Coverage Is Still The Law Of The Land Despite what some of the initial headlines may have implied, the new regulations do not eliminate the ACA’s contraceptive coverage guarantee. Under the ACA, most private health plans in the United States—whether sold to employers, schools, or individuals, or offered by employers that self-insure—must cover dozens of preventive care services without any patient out-of-pocket costs. That list of services includes a set of recommended preventive services for women, and those recommendations, first established in 2011 by an Institute of Medicine committee and reaffirmed in 2016 by an expert panel led by the American College of Obstetricians and Gynecologists, include contraceptive methods and services. More specifically, plans must cover all 18 distinct contraceptive methods used by women, and any new methods identified by the U.S. Food and Drug Administration. They must also cover all related services, including contraceptive counseling, services needed to initiate and discontinue a method, and follow-up care. Moreover, plans may not apply copayments, deductibles, or any other out-of-pocket costs to any of these methods or services. Similarly, plans are sharply limited in their ability to impose formularies, prior authorization requirements, and other administrative barriers to contraception. Federal guidance makes it clear that plans may only try to influence a patient’s choice within a specific contraceptive method (e.g., to favor one hormonal intrauterine device (IUD) over another) and not across methods (e.g., to favor oral contraceptives over the contraceptive ring). Exemptions To The Contraceptive Coverage Guarantee Have Expanded  The contraceptive coverage requirement still applies to most private health plans in the country, but the Trump administration has created major new exceptions. Even before the new regulations, the contraceptive coverage requirement (like the rest of the preventive services requirement) did not apply to so-called grandfathered plans — plans that predated the ACA and have not changed substantively. This was meant to be a temporary exception, and indeed, the proportion of covered workers enrolled in a grandfathered plan has fallen to just 17% in 2017. In addition, before the new regulations, a limited set of religious employers (primarily houses of worship) were exempt from the contraceptive coverage requirement. Beyond that, nonprofit employers and closely held for-profit employers with religious objections were offered an “accommodation” that the Obama administration set up as a compromise. That accommodation allows an employer with religious objections to “step away” from contraceptive coverage—refusing to pay for it, arrange for it or even talk about it—while still ensuring that employees and their dependents receive that coverage directly from the insurance company. The new regulations issued by the Trump administration vastly expand the universe of potential exemptions. One regulation allows any employer—nonprofit or for-profit—to exclude some or all contraceptive methods and services from the health plans it sponsors if[...]



Salvaging MACRA Implementation Through Medicare Advantage

Tue, 17 Oct 2017 13:40:56 +0000

On June 20, 2017, the Centers for Medicare and Medicaid Services (CMS) released the proposed 2018 Medicare Quality Payment Program (QPP) rule. The rule addresses participation requirements for 2018 and future years under the merit-based incentive payment system (MIPS) and the advanced alternative payment model (APM) pathways created by the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015. Although the MACRA proposed rule for 2018 considers counting participation in advanced APM arrangements in Medicare Advantage toward the advanced APM thresholds in 2019, CMS needs to recognize the full spectrum of innovation in the Medicare Advantage program and incentivize participation in a broader array of APMs. At the same time, CMS needs to revise MIPS to better align the two arms of the QPP. Meaningful progress toward both goals can be achieved using Medicare Advantage as the platform. Current Implementation Needs To Change To Achieve The Goals Of MACRA As originally intended, MACRA had three main goals: repeal the sustainable growth rate (SGR) Medicare payment system; stabilize payments for a period of time; and move providers to a value-based payment system. To achieve the third goal, MACRA established the QPP, which aimed to transition providers into viable alternatives to traditional fee-for-service by making fee-for-service increasingly unattractive through MIPS and rewarding participation in APMs. Although there is considerable flexibility in MIPS reporting requirements and financial penalties during the first and likely the second years of implementation, most providers will experience a “rude awakening” of increased administrative burden and deteriorating reimbursements once MIPS is fully implemented. As fee-for-service becomes rapidly untenable, many providers will not have a viable alternative. Under current MACRA regulations and guidance, only a small number of complex, risk-based Medicare Part B models, mostly Center for Medicare and Medicaid Innovation demonstrations, qualify as advanced APMs. There is no clear “on-ramp” for Medicare providers that want to begin the transition along the value continuum but lack the resources to meet the current advanced APM requirements. The early results from current advanced APMs are disappointing, and their long-term success remains uncertain. In addition, the current process for developing, testing, and implementing successful APMs in Medicare may take up to seven years, according to a Congressional Budget Office analysis. Recently, Peter S. Hussey and colleagues considered the effects of MACRA on Medicare spending and use and how the effects might differ under various scenarios. They estimate that physicians’ Medicare payments will be substantially lower under MACRA than they would have been if MACRA had never been passed and the cycle of SGR overrides had continued. They suggest that if MACRA is to fare better than the SGR, well-designed APMs must be available to physicians. Otherwise, there could be unintended consequences for patients, and the MACRA program will fail to meet its value-based payment objective. Assets Of Medicare Advantage To achieve the original goals of the MACRA legislation, Medicare Advantage could serve as a platform to reduce the burden on physician practices, provide an on-ramp to increasingly advanced payment models, and accelerate the transition to a value-based payment system in Medicare. Choice Despite reductions in payments to plans authorized by the Affordable Care Act, Medicare Advantage enrollment has grown 71 percent since 2010. As of 2017, one in three people with Medicare (33 percent or 19 million beneficiaries) is enrolled in a Medicare Advantage plan, and enrollment is projected to grow to at least 41 percent over the next decade. Unlike participation in accountable care organizations, beneficiaries choose to be in Medicare Advantage plans. Because Medicare Advantage’s cost-reductio[...]



A Framework For Understanding ‘Savings’ From Accountable Care Organizations

Tue, 17 Oct 2017 12:33:08 +0000

Medicare’s Accountable Care Organization (ACO) program is the Centers for Medicare and Medicaid Services’ (CMS) flagship population-based payment model. In the ACO program, groups of providers form ACOs and take accountability for the spending and quality of care for the Medicare beneficiaries they serve. The ACO is given a spending target (benchmark) and receives a bonus (i.e. gets to share savings) if actual spending is below the target. In some ACO programs, the ACO must return money to Medicare if spending exceeds the target. The release of the Office of the Inspector General’s (OIG) report on the savings resulting from the Medicare Shared Savings Program’s (MSSP) ACOs has rekindled the debate about the success of ACOs and their viability as a means to curb health care spending growth. This is an important debate, but clarity requires addressing crucial conceptual and semantic questions about the meaning of “savings.” In a previous post, we discussed the analytic issues about savings (specifically issues related to comparison groups). Our main point was that savings must be judged against a reasonable estimate of what the spending on ACO-attributed beneficiaries would have been in the absence of the ACO program. In other words, actual spending must be compared against an appropriate counterfactual level of spending. While CMS’s benchmarks are useful for setting spending targets, as elaborated below they do not always represent the appropriate counterfactual against which to judge ACO savings (nor should they). Savings computed based on comparisons of spending versus benchmarks may thus give misleading estimates of the success of the MSSP, or of ACOs in general. However, even if there is agreement about the counterfactual, there is continued confusion about the meaning of the term “savings” in the context of the ACO program. The complexity of the payment structure in the ACO program means that there are a few ways one could choose to measure savings. The semantic questions here are surprisingly challenging and variation in how terms are used can lead to considerable confusion. Below we attempt to clarify the meanings of “savings” and draw out the implications for the program. Consider three types of “savings.” Utilization Savings: The difference between Medicare fee-for-service (FFS) spending on ACO beneficiaries (without counting the bonus) and the Medicare FFS spending on those beneficiaries had there been no ACO. This is driven by changes in utilization associated with the ACO. Payer Savings: The difference between Medicare program spending with, versus without, the ACO (including bonuses paid and other program fiscal effects, including administrative costs). Societal Savings: The savings achieved because fewer services are delivered and offset by payer and provider administrative costs associated with the ACO program, but ignoring changes in prices or distribution of savings and losses. Utilization Savings Utilization savings is the most common measure of savings in the literature. It reflects changes in spending due to changes in the ACO providers’ pattern of health service provision. Commonly, measures of utilization savings are limited to ACO-attributed patients (i.e. those patients who are part of the population accounted for in the initial budget-setting process). Utilization savings is an important concept because it captures providers’ response to the program’s incentives and speaks to the ability of new payment models to change underlying utilization, which is likely needed if we are to create a fiscally sustainable health care system. However, utilization savings do not measure savings from a payer perspective. Conceptually, it is these utilization “savings” that get “shared” in a “shared savings” program. Payer Savings Payer savings refers to the budget impact on payers. Payer savings differ fr[...]



A New Plan To Rescue The ACA: Medicare-At-55

Mon, 16 Oct 2017 15:16:53 +0000

On October 12, 2017, the Trump Administration announced that it would end subsidies that reduce out-of-pocket payments for low-income individuals. This action might drive insurers out of the exchanges and might encourage younger people to drop their individual insurance plans — thereby destabilizing the individual insurance market. Extending Medicare to the 55-64 age group—who have relatively high health care costs—is a potential fix that could insure the near-elderly and provide stability to the marketplaces. It would remove expensive individuals and families from coverage by private insurance companies, who could in turn reduce premiums for individuals and families below the age of 55. Under this proposal, Medicare-at-55 would be universal for people in the 55-64 age group and they would leave their current private insurance. It would require an increase in the Medicare payroll tax contribution which has not increased proportionately to increases in Medicare spending; other countries sustain their health insurance programs by gradually increasing their payroll tax contributions. To make this plan fiscally sustainable, the United States would need to do the same. The Problem With Making Medicare-At-55 Optional Medicare-at-55 is quite different from proposals suggested by Democrats in 2009 and 2017, which allowed people aged 55-64 to voluntarily buy into Medicare as an alternative to private insurance. The problem with the idea of Medicare buy-in is that relatively few of the near-elderly would choose it. Medicare premiums for this age group—about $8,200 per year for an individual—would be significantly higher than what they currently pay with employer-sponsored insurance and with individual insurance subsidized under the Affordable Care Act (ACA). In addition, under an optional buy-in there would be confusion among potential enrollees on whether to use the buy-in and person-by-person enrollment would be administratively complex. Moreover, the buy-in would raise vexing legislative questions around premium levels, Medigap and Medicare Advantage policies, and whether people could buy-in to Parts A, B, and D separately. Automatic Enrollment, Just Ten Years Earlier  The better approach would be to implement a Medicare-at-55 concept in which everyone would be automatically enrolled in Medicare — just like the current system does for those 65 and above. Upon reaching the age of 55, eligible individuals (almost everyone in the 55-64 age group) would simply receive their red-white-and-blue Medicare card. Private insurers and employers would no longer be responsible for this age group, which would allow private insurers to reduce premiums on younger families because they would have a younger, and typically healthier, pool of people to cover. In 2015, per capita health care costs for people between 55 and 64 years of age were $9,707 compared with $6,637 for the 45-54 age group, $4,442 for the 26-44 cohort, and $2,915 for those between 19 and 25. Once on Medicare at the age of 55, people could choose to get a Medicare supplement through their previous insurer or join a Medicare Advantage plan. While the 55-64 age group has higher health care costs than younger people, they have lower costs than current Medicare beneficiaries, which in 2015 incurred per capita spending of $11,904. Keep in mind that this is not small group to be adding to Medicare’s risk pool. In 2015, there were 41.1 million people in the 55-64 age group. 24 million have access to employer-sponsored insurance, 3 million have subsidized individual insurance under the ACA, 2 million purchase unsubsidized individual insurance, and 3.4 million are uninsured. This leaves an estimated 8 to 9 million already on Medicare and/or Medicaid. How Would We Pay For Medicare-At-55? First, it is noteworthy that from 2010 to 2016, per capita Medicare spe[...]



ACA Repeal Votes Defy Preferences Of Constituents

Mon, 16 Oct 2017 13:21:29 +0000

Despite repeatedly failing to advance legislation through the Senate, Republicans in Congress have not abandoned their goal of repealing and replacing the Affordable Care Act (ACA). The latest attempt at repeal in the form of the Graham-Cassidy bill would have established a per capita cap on federal Medicaid financing, eliminated the individual mandate, and undermined protections for older adults and people with preexisting conditions, by allowing states to opt out of key ACA insurance regulations. It would also have eliminated funding for the ACA’s Marketplace premium and cost-sharing subsidies and Medicaid expansion, and redirected some of that funding toward block grants to states. One puzzling aspect of this and previous repeal efforts is that they nearly succeeded in spite of widespread public support for the core elements of the ACA that would have been overturned. Although almost 80 percent of nonelderly adults favor keeping the Medicaid expansion and nearly 70 percent favor keeping the premium subsidies, previous legislation eliminating or weakening these provisions passed the House by a vote of 217–213 (with House votes by district shown in Exhibit 1) and fell just a few votes short of passing the Senate. ACA protections for people with preexisting conditions—including guaranteed issue, community rating, and essential health benefits—are even more popular, eliciting support of 80 percent to 90 percent of nonelderly adults, and age rating limits are supported by three-quarters of adults. Exhibit 1: US House Of Representatives’ Votes For The American Health Care Act, By Congressional District Source: GovTrack.us. Note: AHCA is American Health Care Act. A possible explanation for the perseverance toward repeal despite its unpopularity is that residents in districts and states where members of Congress voted for repeal may exhibit less support for key ACA provisions compared to those living in districts and states where members voted against repeal. If favorability toward these provisions varies widely across politically polarized Congressional districts and states, voting patterns in Congress may simply reflect legislators’ responsiveness to the preferences of their constituents. In contrast, if favorability toward ACA provisions is high across districts and states, it would indicate that the push for repeal is motivated by factors beyond constituent demands. Most Nonelderly Adults Support Keeping Core ACA Provisions In Districts Where Members Of The House Voted For Repeal To understand the link between congressional votes and public opinion on ACA repeal, we used data from the Urban Institute’s March 2017 Health Reform Monitoring Survey to examine public support for keeping or repealing core ACA provisions among a sample of more than 9,500 nonelderly adults—and the potential impact of repeal on coverage—based on how their member of the US House of Representatives voted for the American Health Care Act (AHCA) last May and how their senators voted for the Better Care Reconciliation Act (BCRA) and Obamacare Repeal and Reconciliation Act (ORRA) last July. Senators voted on a third repeal bill, the Health Care Freedom Act, that would have eliminated the individual mandate without directly targeting other core coverage provisions described in the survey. We found that although support was somewhat lower in House districts where representatives voted for the AHCA, 75.2 percent of adults in these districts supported keeping the Medicaid expansion and 64.3 percent of them supported keeping the premium subsidies (Exhibit 2). In districts where representatives voted against AHCA, support was 81.0 percent for Medicaid expansion and 72.6 percent for the premium subsidies. There were no differences by districts’ House votes in support for the ACA’s guaranteed issue and c[...]



A Fateful Thursday For The ACA: Likely Effects And Legal Reactions

Sat, 14 Oct 2017 19:28:28 +0000

Thursday, October 12, 2017, was one of the most eventful days in the history of the Affordable Care Act.  Late Thursday morning, President Trump released an executive order directing the Departments of Labor, Treasury, and Health and Human Services to begin the process of drafting rules that will expand the use of association health plans, exempting small employer plans from the ACA’s small group consumer protections and perhaps preempting state regulation; expand the length and renewability of short-term coverage; and expand the ability of employers to use health reimbursement accounts to shift coverage of their employees to the individual market. That evening, the administration announced that it will no longer be reimbursing insurers for the reductions in out-of-pocket limits, deductibles, and other forms of cost sharing that the ACA requires insurers to provide to enrollees in silver plans with incomes below 250 percent of poverty and to Native Americans. These two steps obviously furthered the administration’s two-part strategy to undermine the ACA. President Trump is reportedly furious that Congress failed to repeal the ACA and has set out to single-handedly dismantle it himself. The cost-sharing reduction (CSR) payment cut-off will, in tandem with other steps taken by the administration to discourage enrollment in the individual market, drive up the cost of coverage. The executive order will open escape routes so that healthy people will leave the ACA-compliant individual market for cheaper, non-compliant forms of coverage. This post will explore first the likely practical effects of President Trump’s October 12 actions. It will then analyze the legal challenges to those actions that began brewing on Friday, October 13. Effects Of The Executive Order And CSR Payment Cutoff Executive Order The executive order is unlikely to have an immediate effect. It calls for the agencies to draft rules, which will go through notice and comment rulemaking. The earliest they could possibly go into effect would be early in 2018. Once the association plan rules go into effect, however, small groups could begin to drop ACA-compliant coverage and move into the association market.  Similarly, healthy individuals insured in ACA-compliant individual market coverage could drop it in favor of short-term coverage. Healthy individuals who lose employer coverage and who would have purchased ACA-compliant could instead purchase short-term coverage. The risk pool is likely to begin to erode further, with this erosion reflected in 2019 individual and small group market rates. CSR Payments The effect of the CSR cutoff is more difficult to predict.  A group of bloggers—David Anderson, Andrew Sprung, Charles Gaba, and Louise Norris—have looked at how each state is responding to the end of the CSR payments, and at how each state’s response will affect the damage the ending of the CSR payments is likely to have for 2018. Before reviewing their findings, three observations are in order. First, the announcement of the CSR cutoff days before open enrollment began was timed to do great damage to the ACA market. President Trump stated that he relied on advice from the Justice Department that the payments were illegal; more on that later. But if that is the case, President Trump has been making illegal—unconstitutional—payments since January. The cut-off was apparently announced now because the insurers have, as of September 27, signed their exchange contracts and set their rates for 2018, and revising them to allow the marketplaces to open on November 1, for an already shortened open enrollment period, will be difficult. But second, President Trump has been foreshadowing a CSR cutoff for months, and so many states and insurers had already taken action to accommodate the cutoff in their rate[...]