The ARP comes to the rescue of the ACA, for now

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On Thursday, President Biden signed the American Rescue Plan (ARP) Act of 2021 into law, committing nearly $1.9T of federal spending to boost the nation’s recovery from the coronavirus pandemic. In addition to direct payments to American families, extension of unemployment benefits, several anti-poverty measures, and aid to state and local governments, the plan also contains several key healthcare measures.

Approved by Congress on a near party-line vote using the budget reconciliation process, the law includes the broadest expansion of the 2010 Affordable Care Act (ACA) to date. It extends subsidies for upper-middle income individuals to purchase coverage on the Obamacare exchanges, caps premiums for those higher earners at a substantially lower level, and boosts subsidies for those at the lower end of the income scale.

The Congressional Budget Office (CBO) estimates that expanded ACA subsidies in the ARP will result in 2.5M more Americans gaining coverage in the next two years. Fully subsidized COBRA coverage for workers who lost their jobs due to COVID is also extended through the end of September, which the CBO estimates will benefit an additional 2M unemployed Americans.

The ARP also puts in place new support for Medicaid, enhancing coverage for home-based care, maternity services, and COVID testing and vaccination, and providing new incentives for the 12 states which haven’t yet expanded Medicaid eligibility under the ACA to do so. In addition to the ACA’s 90 percent match for those states’ Medicaid expansion populations, the lucky dozen will also receive a 5 percent bump to federal matching for the rest of their Medicaid populations should they choose to expand.
Three policy changes of keen interest to providers were left out of the final version of the bill. First, while a special relief fund of $8.5B was created for rural providers, there was no additional allocation of relief funds for hospitals and other providers, similar to the $178B allocated by the CARES Act, despite initial proposals of up to $35B in additional funding. (Around $25B of the initial round of provider relief is still unspent.) Second, the ARP did not extend or alter the repayment schedule for advance payments to providers made last year, in spite of industry pressure to implement more favorable repayment conditions. Finally, the new law does not extend last year’s pause on sequester-related cuts to Medicare reimbursement, although the House is expected to consider a separate measure to address that issue next week.

Notably, the coverage-related provisions of the ARP are only temporary, lasting through September of next year. That sets up the 2022 midterm elections as yet another campaign cycle dominated by promises to uphold and protect the Affordable Care Act—by then a 12-year-old law bolstered by this week’s COVID recovery legislation.

Democrats align around a health policy platform

Abstract Word Cloud For Health Policy With Related Tags And Terms ...


Promising that “we are going to at last build the health care system the American people have always deserved”, a joint task force of health policy advisors from the Biden and Sanders campaigns this week released a unified set of proposals that will serve as part of the former Vice President’s campaign platform for the November election.

While the document does not include Sanders’ signature “Medicare for All” proposal, it does support a government-run public insurance option that would be available to all Americans, at income-adjusted, subsidized rates—including free coverage for those with low incomes. It also promises to expand Medicare benefits to include dental, vision, and hearing coverage, and to extend Medicare eligibility to those age 60 and above.

For those who lose their health coverage due to the COVID pandemic, the unity document endorses having the government pick up the tab for COBRA benefits and shifting enrollees into premium-free coverage on the Obamacare exchanges when their COBRA eligibility expires.

It also promises greater investment in public health resources, including increased funding for the CDC, and funding to recruit 100,000 contact tracers nationwide.

Other key components of the proposal include eliminating “surprise billing”, reducing drug costs, addressing racial and gender-based health inequities, and bolstering investment in scientific research.

This week’s document represents an important step in unifying the progressive and moderate wings of the Democratic party around key health policy principles. Should Biden win in November, and if Democrats gain control of the Senate, we’d expect quick action on many of these proposals.

Clearly the most difficult would be the public option and Medicare expansion, which would require lengthy negotiation with various industry groups to garner sufficient political support. Similar to the 2009 process that led to the Affordable Care Act, we would likely see a year’s worth of political horse-trading, leading to passage of some compromise legislation before the midterm elections in 2022.

All of that in the midst of an ongoing pandemic and likely prolonged economic downturn—both of which will probably allow for the passage of more far-reaching legislation than might otherwise be possible.



Eligibility for ACA Health Coverage Following Job Loss

Eligibility for ACA Health Coverage Following Job Loss

Eligibility for ACA Health Coverage Following Job Loss – Methods ...

The economic consequences of the coronavirus pandemic have led to historic level of job loss in the United States. Social distancing policies required to address the crisis have led many businesses to cut hours, cease operations, or close altogether. Between March 1st and May 2nd, 2020, more than 31 million people had filed for unemployment insurance. Actual loss of jobs and income are likely even higher, as some people may be only marginally employed or may not have filed for benefits. Some of these unemployed workers may go back to work as social distancing curbs are relaxed, though further job loss is also possible if the economic downturn continues or deepens.

In addition to loss of income, job loss carries the risk of loss of health insurance for people who were receiving health coverage as a benefit through their employer. People who lose employer-sponsored insurance (ESI) often can elect to continue it for a period by paying the full premium (called COBRA continuation) or may become eligible for Medicaid or subsidized coverage through the Affordable Care Act (ACA) marketplaces. Over time, as unemployment benefits end, some may fall into the “coverage gap” that exists in states that have not expanded Medicaid under the ACA.

In this analysis, we examine the potential loss of ESI among people in families where someone lost employment between March 1st, 2020 and May 2nd, 2020 and estimate their eligibility for ACA coverage, including Medicaid and marketplace subsidies, as well as private coverage as a dependent (see detailed Methods at the end of this brief). To illustrate eligibility as their state and federal unemployment insurance (UI) benefits cease, we show eligibility for this population as of May 2020 and January 2021, when most will have exhausted their UI benefits.

What are coverage options for people losing ESI?

Eligibility for health coverage for people who lose ESI depends on many factors, including income while working and family income while unemployed, state of residence, and family status. Some people may be ineligible for coverage options, and others may be eligible but opt not to enroll. Some employers may temporarily continue coverage after job loss (for example, through the end of the month), but such extensions of coverage are typically limited to short periods.

Medicaid: Some people who lose their jobs and health coverage—especially those who live in states that expanded Medicaid under the ACA— may become newly eligible1 for Medicaid if their income falls below state eligibility limits (138% of poverty in states that expanded under the ACA). For Medicaid eligibility, income is calculated based on other income in the family plus any state unemployment benefit received (though the $600 per week federal supplemental payment available through the end of July is excluded). Income is determined on a current basis, so prior wages for workers recently unemployed are not relevant. In states that have not expanded Medicaid under the ACA, eligibility is generally limited to parents with very low incomes (typically below 50% of poverty and in some states quite a bit less); thus many adults may fall into the “coverage gap” that exists for those with incomes above Medicaid limits but below poverty (which is the minimum eligibility threshold for marketplace subsidies under the ACA). Undocumented immigrants are ineligible for Medicaid, and recent immigrants (those here for fewer than five years) are ineligible in most cases.

Marketplace: ACA marketplace coverage is available to legal residents who are not eligible for Medicaid and do not have an affordable offer of ESI; subsidies for marketplace coverage are available to people with family income between 100% and 400% of poverty. Some people who lose ESI may be newly-eligible for income-based subsidies, based on other family income plus any state and new federal unemployment benefit received (including the $600 per week federal supplement, unlike for Medicaid).2 While current income is used for Medicaid eligibility, annual income for the calendar year is used for marketplace subsidy eligibility. Advance subsidies are available based on estimated annual income, but the subsidies are reconciled based on actual income on the tax return filed the following year. People who lose ESI due to job loss qualify for a special enrollment period (SEP) for marketplace coverage.3 As with Medicaid, undocumented immigrants are ineligible for marketplace coverage or subsidies. However, recent immigrants, including those whose income makes them otherwise eligible for Medicaid, can receive marketplace subsidies.

ESI Dependent Coverage: People who lose jobs may be eligible for ESI as a dependent under a spouse or parent’s job-based coverage. Some people may have been covered as a dependent prior to job loss, and some may switch from their own coverage to coverage as a dependent.

COBRA: Many people who lose their job-based insurance can continue that coverage through COBRA, although it is typically quite expensive since unemployed workers generally have to pay the entire premium – employer premiums average $7,188 for a single person and $20,576 for a family of four – plus an additional 2%. People who are eligible for subsidized coverage through Medicaid or the marketplaces are likely to opt for that coverage over COBRA, though COBRA may be the only option available to some people who are income-ineligible for ACA coverage.

Short-term plans: Short-term plans, which can be offered for up to a year and can sometimes be renewed under revised rules from the Trump administration, are also a potential option for people losing their employer-sponsored insurance. These plans generally carry lower premiums than COBRA or ACA-compliant coverage, as they often provider more limited benefits and usually deny coverage to people with pre-existing conditions. Even when coverage is issued, insurers generally may challenge benefit claims that they believe resulted from pre-existing medical problems; given the long latency between initial infection and sickness with COVID-19, these plans are riskier than usual during the current pandemic. People cannot use ACA subsidies toward short-term plan premiums.

Our analysis examines eligibility for Medicaid, marketplace subsidies, and dependent ESI coverage. We do not estimate enrollment in COBRA, short-term plans, or temporary continuation of ESI. See Methods for more details.

How does coverage and eligibility change following job loss?

Between March 1st, 2020 and May 2nd, 2020, we estimate that nearly 78 million people lived in a family in which someone lost a job. Most people in these families (61%, or 47.5 million) were covered by ESI prior to job loss. Nearly one in five (17%) had Medicaid, and close to one in ten (9%) were uninsured. The remaining share either had direct purchase (marketplace) coverage (7%) or had other coverage such as Medicare or military coverage (6%) (Figure 1).

Eligibility for ACA Health Coverage Following Job Loss | The Henry ...

We estimate that, as of May 2nd, 2020, nearly 27 million people could potentially lose ESI and become uninsured following job loss (Figure 1). This total includes people who lost their own ESI and those who lost dependent coverage when a family member lost a job and ESI. Additionally, some people who otherwise would lose ESI are able to retain job-based coverage by switching to a plan offered to a family member: we estimate that 19 million people switch to coverage offered by the employer of a working spouse or parent. A very small number of people who lose ESI (1.6 million) also had another source of coverage at the same time (such as Medicare) and retain that other coverage. These coverage loss estimates are based on our assumptions about who likely filed for UI as of May 2nd, 2020 and the availability of other ESI options in their family (see Methods for more detail).

Among people who become uninsured after job loss, we estimate that nearly half (12.7 million) are eligible for Medicaid, and an additional 8.4 million are eligible for marketplace subsidies, as of May 2020 (Figure 2). In total, 79% of those losing ESI and becoming uninsured are eligible for publicly-subsidized coverage in May. Approximately 5.7 million people who lose ESI due to job loss are not eligible for subsidized coverage, including almost 150,000 people who fall into the coverage gap, 3.7 million people ineligible due to family income being above eligibility limits, 1.3 million people who we estimate have an affordable offer of ESI through another working family member, and about 530,000 people who do not meet citizenship or immigration requirements. We project that very few people fall into the coverage gap immediately after job loss (as of May 2020) because wages before job loss plus unemployment benefits (including the temporary $600 per week federal supplement added by Congress) push annual income for many unemployed workers in non-expansion states above the poverty level, making them eligibility for ACA marketplace subsidies for the rest of the calendar year.

By January 2021, when UI benefits cease for most people, we estimate that eligibility shifts to nearly 17 million being eligible for Medicaid and about 6 million being eligible for marketplace subsidies (Figure 2), assuming those who are recently unemployed have not found work. Many unemployed workers who are eligible for ACA marketplace subsidies during 2020 would instead be eligible for Medicaid or fall into the coverage gap during 2021. The number in the coverage gap grows to 1.9 million (an increase of more than 80% of its previous size), and the number ineligible for coverage due to income shrinks to 0.9 million.

Estimates of coverage loss and eligibility vary by state, depending largely on underlying state employment by industry and Medicaid expansion status. Not surprisingly, states in which the largest number of people are estimated to lose ESI are large states with many people working in affected industries (Appendix Table 1). Eight states (California, Texas, Pennsylvania, New York, Georgia, Florida, Michigan, and Ohio) account for just under half (49%) of all people who lose ESI. Five of the top eight states have expanded Medicaid, and people eligible for Medicaid among the potentially newly uninsured as of May 2020 in these five states account for 40% of all people in that group nationally. Overall, patterns by state Medicaid expansion status show that people in expansion states are much more likely to be eligible for Medicaid, while those in non-expansion states are more likely to qualify for marketplace subsidies (Figure 3). However, the number of people qualifying for marketplace subsidies is similar across the two sets of states, as more people live in expansion states. Three states that have not expanded Medicaid, including Texas, Georgia, and Florida, account for 30% of people who become marketplace tax credit eligible nationally in May 2020. Assuming unemployment extends into 2021 when UI benefits would likely expire for most families, the proportion eligible for Medicaid would increase in expansion states while non-expansion states may see more nonelderly adults moving into the Medicaid coverage gap (Figure 4; Appendix Table 2).

Figure 3: May 2020 Eligibility for ACA Coverage among People Becoming Uninsured Due to Loss of Employer-Sponsored Insurance, by State Medicaid Expansion Status

Figure 4: January 2021 Eligibility for ACA Coverage among People Becoming Uninsured Due to Loss of Employer-Sponsored Insurance, by State Medicaid Expansion Status

Nearly 7 million people losing ESI and becoming uninsured are children, and the vast majority of them are eligible for coverage through Medicaid or CHIP. Within the 26.8 million people losing ESI and becoming uninsured in May 2020, 6.1 million are children. Because Medicaid/CHIP income eligibility limits for children are generally higher than they are for adults, the vast majority of these children are eligible for Medicaid/CHIP in May 2020 (5.5 million, or 89%) or January 2021 (5.8 million, or 95%).


Given the health risks facing all Americans right now, access to health coverage after loss of employment provides important protection against catastrophic health costs and facilitates access to needed care. Unemployment Insurance filings continue to climb each week, and it is likely that people will continue to lose employment and accompanying ESI for some time, though some of them will return to work as social distancing curbs are loosened. The ACA expanded coverage options available to people, and we estimate that the vast majority of people who lose ESI due to job loss will be eligible for ACA assistance either through Medicaid or subsidized marketplace coverage. However, some people will fall outside the reach of the ACA, particularly in January 2021 when UI benefits cease for many and some adults fall into the Medicaid coverage gap due to state decisions not to expand coverage under the ACA.

Both ACA marketplace subsidies and Medicaid are counter-cyclical programs, expanding during economic downturns as people’s incomes fall. In return for additional federal funding to help states finance their share of Medicaid cost during the public health crisis, states must maintain eligibility standards and procedures that were in effect on January 1, 2020 and must provide continuous eligibility through the end of the public health emergency, among other requirements. These provisions may help eligible individuals enroll in and maintain Medicaid, particularly in light of state and federal actions prior to the crisis to increase eligibility verification requirements or transition people off Medicaid.

Our estimates only examine eligibility among people who lost ESI due to job loss and potentially became uninsured. Additional uninsured individuals—including some of the 9% of the 78 million individuals in families where someone lost employment—may also be eligible for Medicaid or subsidized coverage. It is possible that contact with state UI systems may lead them to seek and enroll in coverage, even if they were eligible for financial assistance before job loss but uninsured.

It is unclear whether people losing ESI and becoming uninsured will enroll in new coverage. We did not estimate take-up or enrollment in coverage options but rather only looked at eligibility for coverage. Even before the coronavirus crisis, there were millions of people eligible for Medicaid or marketplace subsidies who were uninsured. Eligible people may not know about coverage options and may not seek coverage; others may apply for coverage but face challenges in navigating the application and enrollment process. Still others may find marketplace coverage, in particular, unaffordable even with subsidies. As policymakers consider additional efforts to aid people, expanding outreach and enrollment assistance, which have been reduced dramatically by the Trump Administration, could help people maintain coverage as they lose jobs.

This is the first economic downturn during which the ACA will be in place as a safety net for people losing their jobs and health insurance. The Trump Administration is arguing in case before the Supreme Court that the ACA should be overturned; a decision is expected by next Spring. The ACA has gaps, and for many the coverage may be unaffordable. However, without it, many more people would likely end up uninsured as the U.S. heads into a recession.





Employers split from health care industry

Employers split from health care industry over coronavirus demands ...

Several large employer groups this week refused to sign on to funding requests they consider a “handout” for hospitals and insurers, according to three people close to the process.

The big picture: Coronavirus spending bills are sharpening tensions between the employers that fund a significant portion of the country’s health care system and the hospitals, doctors and insurers that operate it, Bob reports.

Driving the news: The industry’s most recent request — written primarily by the large hospital and health insurance lobbying groups — focused on a few items for the next coronavirus legislation:

  • Providing subsidies to maintain employer-sponsored insurance, which already receives a large tax break, as well as providing subsidies for COBRA for people who have lost their jobs.
  • Increasing subsidies for Affordable Care Act plans and creating a special ACA enrollment window.
  • Opposing the use of the industry’s bailout funds to pay for uninsured COVID-19 patients at Medicare rates.

Between the lines: Employers know they get charged a lot more for health care services compared with public insurers, but many weren’t keen about urging Congress to “set up a government program to pay commercial reimbursements,” said an executive at a trade group that represents large corporations.

The other side: Several health care groups that signed the letter dismissed the idea of any disagreement with employers.




Trump rejects Obamacare special enrollment period amid pandemic

Trump rejects opening ObamaCare special enrollment period amid ...

Before the coronavirus outbreak, nearly 30 million Americans were uninsured and as many as 44 million were under-insured, paying for bare-bones plans with soaring deductibles and copays. Today, millions more Americans will begin losing their employer-based health insurance because they’ve lost their jobs during this pandemic.

Meanwhile, the Trump administration is still actively trying to repeal the entirety of the Affordable Care Act in court, which would cause an additional 20 million people to lose insurance *in the middle of a pandemic*.

And today, Trump refused to reopen ACA enrollment to those millions of uninsured Americans for a special enrollment window, leaving them without any affordable options to get covered. People are going to die because they can’t afford to seek treatment or end up saddled with thousands of dollars of medical debt if they do. Remember this the next time someone tries to tell you Medicare for All is too radical.

What do you think?

The Trump administration has decided against reopening Obamacare enrollment to uninsured Americans during the coronavirus pandemic, defying calls from health insurers and Democrats to create a special sign-up window amid the health crisis.

President Donald Trump and administration officials recently said they were considering relaunching, the federal enrollment site, and insurers said they privately received assurances from health officials overseeing the law’s marketplace. However, a White House official on Tuesday evening told POLITICO the administration will not reopen the site for a special enrollment period, and that the administration is “exploring other options.”

The annual enrollment period for closed months ago, and a special enrollment period for the coronavirus could have extended the opportunity for millions of uninsured Americans to newly seek out coverage. Still, the law already allows a special enrollment for people who have lost their workplace health plans, so the health care law may still serve as a safety net after a record surge in unemployment stemming from the pandemic.

Numerous Democratic-leaning states that run their own insurance markets have already reopened enrollment in recent weeks as the coronavirus threat grew. The Trump administration oversees enrollment for about two-thirds of states.

Insurers said they had expected Trump to announce a special enrollment period last Friday based on conversations they had with officials at the Centers for Medicare and Medicaid Services, which runs enrollment. It wasn’t immediately clear why the Trump administration decided against the special enrollment period. CMS deferred comment to the White House.

Trump confirmed last week he was seriously considering a special enrollment period, but he also doubled down on his support of a lawsuit by Republican states that could destroy the entire Affordable Care Act, along with coverage for the 20 million people insured through the law.

People losing their workplace coverage have some insurance options outside of the law’s marketplaces. They can extend their employer plan for up to 18 months through COBRA, but that’s an especially pricey option. Medicaid is also an option for low-income adults in about two-thirds of states that have adopted Obamacare’s expansion of the program.

Short-term health insurance alternatives promoted by Trump, which allow enrollment year-round, is also an option for many who entered the crisis without coverage. Those plans offer skimpier coverage and typically exclude insurance protections for preexisting conditions, and some blue states like California and have banned them or severely restricted them. The quality of the plans vary significantly and, depending on the contract, insurers can change coverage terms on the fly and leave patients with exorbitant medical bills.

Major insurers selling Obamacare plans were initially reluctant to reopen the law’s marketplaces, fearing they would be crushed by a wave of costs from Covid-19, the disease caused by the novel coronavirus. But the main insurance lobby, America’s Health Insurance Plans, endorsed the special enrollment period roughly two weeks ago while also urging lawmakers to expand premium subsidies to make coverage more affordable for middle-income people.

Congress in last week’s $2 trillion stimulus passed on that request, as well as insurers’ petition for an open-ended government fund to help stem financial losses from an unexpected wave in coronavirus hospitalizations.

Democrats pushing for the special enrollment period are also grappling with the high costs facing many people with insurance despite new pledges from plans to waive cost-sharing. Obamacare plans and a growing number of those offered by employers impose hefty cost-sharing and high deductibles that could still burden infected Americans with thousands of dollar in medical bills.

House Energy and Commerce Chairman Frank Pallone (D-N.J.) on a press call Monday contended that “we also need to have free treatment” after Congress eliminated out-of-pocket costs for coronavirus tests.

“We did the testing, which is now free, and everybody, regardless of their insurance, gets it,” Pallone said. “But that has to be for the treatment as well.”





Coronavirus exposing holes in employer insurance

The coronavirus is exposing the holes in employer health insurance ...

A record 3.3 million people filed for unemployment in one week, in the wake of the coronavirus outbreak, but people didn’t just lose their jobs. Many also lost the health insurance that came with the job, Axios’ Bob Herman reports.

Why it matters: U.S. workers, even those who feel relatively secure in their health benefits, are a pandemic away from falling into the ranks of the uninsured.

Many of the people losing their jobs right now may not have had coverage to begin with — which would make the coronavirus-related disruption smaller, but still highlights the very large holes in this system.

  • The concern: People who get the virus but don’t have insurance are susceptible to high medical bills, or even death if they avoid or are denied treatment.

The big picture: People who lose their jobs have some options.

  • COBRA: This option allows people to keep their employer coverage for up to 18 months. However, people have to pay the full insurance premium — an average of $1,700 a month for a family plan.
  • Medicaid: State Medicaid agencies determine eligibility on current income, so this may be the easiest, lowest-cost way for people to get health coverage.
  • Affordable Care Act plans: The health care law created marketplaces for coverage, and people who lose their jobs can sign up outside the standard enrollment window.
  • Short-term plans: These stopgap plans, promoted by the Trump administration, provide some coverage but often don’t cover major hospitalizations.





What health care is getting out of the stimulus package

Senate passes $2 Trillion coronavirus economic stimulus plan, it ...

Congress’ big stimulus package will provide more than $100 billion and several favorable payment policies to hospitals, doctors and others in the health care system as they grapple with the coronavirus outbreak.

The big picture: Hospitals, including those that treat a lot of rural and low-income patients, are getting the bailout they asked for — and then some.

The cornerstone provision is a no-strings-attached $100 billion fund for hospitals and other providers so they “continue to receive the support they need for COVID-19 related expenses and lost revenue,” according to a summary of the legislation.

  • It’s unclear how that money would be divvied up. One lobbyist speculated the funds would go to the “hardest-hit areas first and those areas that are next expected to get hit,” but that has not been clarified.

The bill provides many other incentives for the industry.

  • Hospitals that treat Medicare patients for COVID-19 will get a 20% payment increase for all services provided. That means Medicare’s payment for these types of hospital stays could go from $10,000 to $12,000, depending on the severity of the illness.
  • Employers and health insurers will be required to pay hospitals and labs whatever their charges are for COVID-19 tests if a contract is not in place. By comparison, Medicare pays $51.33 for a commercial coronavirus test.
  • Medicare’s “sequestration,” which cuts payments to providers by 2%, will be lifted until the end of this year.
  • Labs won’t face any scheduled Medicare cuts in 2021, and won delays in future payment cuts as well.

What’s missing: Patients who are hospitalized with COVID-19 could still be saddled with large, surprise bills for out-of-network care.

  • There also are no subsidies for COBRA coverage, which employers wanted for people who lost their jobs. However, people who are laid off are able to sign up for a health plan on the Affordable Care Act’s marketplaces or could qualify for Medicaid.