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Category Archives: Uncategorized
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Following the ACA Repeal-and-Replace Effort, Where Does the U.S. Stand on Insurance Coverage?
Conclusion and Policy Implications
The findings of this study could inform both short- and long-term actions for policymakers seeking to improve the affordability of marketplace plans and reduce the number of uninsured people in the United States.
Short-Term
The most immediate concern for policymakers is ensuring that the 17 million to 18 million people with marketplace and individual market coverage are able to enroll this fall.
Congress could take the following three steps:
- The Trump administration has not made a long-term commitment to paying insurers for the cost-sharing reductions for low-income enrollees in the marketplaces, which insurers are required to offer under the ACA. Congress could resolve this by making a permanent appropriation for the payments. Without this commitment, insurers have already announced that they are increasing premiums to hedge against the risk of not receiving payments from the federal government. Since most enrollees receive tax credits, higher premiums also will increase the federal government’s costs.9
- While it appears that most counties will have at least one insurer offering plans in the marketplaces this year, Congress could consider a fallback health plan option to protect consumers if they do not have a plan to choose from, with subsidies available to help qualifying enrollees pay premiums.
- Reinsurance to help carriers cover unexpectedly high claims costs.10 During the three years in which it was functioning, the ACA’s transitional reinsurance program lowered premiums by as much as 14 percent.
The executive branch can also play an important role in two ways:
- Signaling to insurers participating in the marketplaces that it will enforce the individual mandate. Uncertainty over the administration’s commitment to the mandate, like the cost-sharing reductions, is leading to higher-than-expected premiums for next year.
- Affirming the commitment to ensuring that all eligible Americans are aware of their options and have the tools they need to enroll in the coverage that is right for them during the 2018 open enrollment period, which begins November 1. The survey findings indicate that large shares of uninsured Americans are unaware of the marketplaces and that enrollment assistance makes a difference in whether people sign up for insurance.
Long-Term
The following longer-term policy changes will likely lead to affordability improvement and reductions in the number of uninsured people.
- The 19 states that have not expanded Medicaid could decide to do so.
- Alleviate affordability issues for people with incomes above 250 percent of poverty by:
- Allowing people earning more than 400 percent of poverty to be eligible for tax credits. This would cover an estimated 1.2 million people at an annual total federal cost of $6 billion, according to a RAND analysis.11
- Increasing tax credits for people with incomes above 250 percent of poverty.
- Allowing premium contributions to be fully tax deductible for people buying insurance on their own; self-employed people have long been able to do this.
- Extending cost-sharing reductions for individuals with incomes above 250 percent of poverty, thus making care more affordable for insured individuals with moderate incomes.
- Consider immigration reform and expanding insurance options for undocumented immigrants.
In 2002, the Institute of Medicine concluded that insurance coverage is the most important determinant of access to health care.12 In the ongoing public debate over how to provide insurance to people, the conversation often drifts from this fundamental why of health insurance. At this pivotal moment, more than 30 million people now rely on the ACA’s reforms and expansions. Nearly 30 million more are uninsured — because of the reasons identified in this survey. It is critical that the health of these 60 million people, along with their ability to lead long and productive lives, be the central focus in our debate over how to improve the U.S. health insurance system, regardless of the approach ultimately chosen.
How Would Coverage, Federal Spending, and Private Premiums Change if the Federal Government Stopped Reimbursing Insurers for the ACA’s Cost-Sharing Reductions?
http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2017/rwjf440003
Elimination of federal cost-sharing reductions could increase marketplace spending by 18 percent or increase the uninsured by 9.4 million, depending on insurer response.
The Issue
The Affordable Care Act (ACA) requires insurers to provide cost-sharing reductions (CSRs) that lower deductibles, co-payments, co-insurance, and out-of-pocket maximums for people eligible for tax credits and with incomes below 250 percent of the federal poverty level. With current policy uncertainty surrounding these CSRs, there are multiple future scenarios, but all involve increases in insurance premiums for consumers and there is a potential for large reductions in the insured population.
Key Findings
The report analyzes three potential scenarios and outcomes:
- Insurers have enough time before the start of the plan year to incorporate their anticipated CSR costs into a surcharge placed on silver plan premiums.
- Insurers exit the marketplaces in response to the loss of CSRs and other policy uncertainties and changes.
- The federal government does not reimburse insurers for CSRs and lawmakers alter the ACA so that insurers are no longer required to pay CSRs to eligible enrollees.
In 2018, the number of uninsured Americans could increase by 9.4 million, and average premiums could increase by nearly 37 percent, if insurers abandon the marketplaces because of a decision to eliminate federal reimbursement of health insurance CSRs.
About the Urban Institute
The nonprofit Urban Institute is dedicated to elevating the debate on social and economic policy. For nearly five decades, Urban scholars have conducted research and offered evidence-based solutions that improve lives and strengthen communities across a rapidly urbanizing world. Their objective research helps expand opportunities for all, reduce hardship among the most vulnerable, and strengthen the effectiveness of the public sector. Visit the Urban Institute’s Health Policy Center for more information specific to its staff and its recent research.
ONC Pushes Public Health Agencies to Improve HIE Integration
https://ehrintelligence.com/news/onc-pushes-public-health-agencies-to-improve-hie-integration
The few public health agencies with HIE integration have reported more complete, higher quality data than those without a connection.
An ONC resource on how public health agencies utilize health information exchange (HIE) integration contains best practices and insights using interviews from public health agencies in 16 jurisdictions.
The findings detailed in the report focus on strategies for public health and HIE integration across six categories: leadership, technical, financial, privacy and security, policy, and health IT developers.
ONC partnered with Clinovations Government + Health (CGH) to examine HIE use among public health agencies. These state and community agencies can assist in improving the health of populations through disease prevention activities using data from public health screening and treatment services, laboratories, pharmacies, environmental health monitors, emergency medical services, local public health agencies, and clinical care providers.
Public health agencies function within states and communities and collect data from providers to use for data registries and disease surveillance systems. With an HIE connection, public health agencies can benefit from improved interoperability and reduce redundant connections.
While public health information systems with HIE integration have increased in recent years according to ONC, the practice is not yet widespread. In 2012, a survey from the Association of State and Territorial Health Officials (ASTHO) found 13 state public health agencies received lab results and nine received reportable diseases through HIE organizations.
“This trend occurs as researchers discover instances of higher quality in public health data transmitted from HIE organizations, as compared to clinical information systems,” stated the report. “For example, a 2013 investigation of electronic lab report messages finds data enriched by an HIE organization is more complete, compared to data from clinical systems.”
Public health systems with integrated HIE organizations have also been shown to yield improvements in care coordination and clinical efficiency, according to qualitative research in upstate New York, central Texas, Indiana, and New Mexico.
Still, HIE integration within public health systems is a relatively recent undertaking.
ONC highlighted three factors as contributing to this lack of integration:
- An existing reporting infrastructure already facilitates public health reporting for health care providers.
- The HIE organization’s technical solution does not often supply public health agencies with the level of data required for public health functions
- Limited resources are available to dedicate to HIE infrastructure.
In its report, ONC determined that a combination of flexible, standardized technical solutions, policy enabling standardized public health reporting through HIE organizations and secondary data use, and affordable connectivity solutions offered by health IT developers could address these issues.
Interviewees highlighted a number of objectives driving the need to encourage more HIE integration in this care setting.
Most stated HIE integration could streamline the number of connections and thereby reduce costs for healthcare providers, HIE organizations, and public health agencies sharing information. Additionally, integration could support providers in achieving public health requirements for the EHR incentive programs.
Other interviewees expressed interest in developing a sustainable platform for clinical and public health data exchange for improved analytics and quality measurement.
To achieve these aims, ONC outlined ways public health agencies can overcome barriers to HIE integration — specifically, lack of standardization, gaps in standard use and adoption, lack of aligned messaging standards, and inconsistent data quality pose issues in integration.
Improving standards for public health data exchange is especially necessary.
“EHRs that meet ONC’s Health IT Certification Program requirements support transport protocols such as Direct for transport of Continuity of Care Documents (CCDs),” wrote ONC. “Public health content is standardized at the provider (EHR) and public health level, but the method of transport is not. The HL7 implementation guides and certification standards for public health information exchange do not require any specific transport mechanism, which can vary by state or region.”
Using transport methods such as the Direct standard could assist in improving standardization in public health data exchange.
To help public health agencies more efficiently exchange health data, ONC provided a summary of best practices for HIE use.
“One jurisdiction’s HIE organization respondents describe an increasingly electronic environment as being overall good for the community with the ability to share information across trading partners,” stated ONC.
“However, public health agency respondents caution against the growing electronic gap between public health and health care providers, where health care providers increasingly use health IT with exchange capabilities, but public health agencies do not have comparable technology to participate in exchanges,” the agency advised.
Finally, ONC emphasized the need for collaboration between public health agencies, HIEs, healthcare providers, and health IT developers to work toward bidirectional, standards-based health data exchange.
“Standards alignment must integrate public health information systems and HIE organizations, with transport mechanisms and terminologies meeting all of the public health data requirements,” maintained ONC.
How to turn healthcare’s single-payer threat into a reality
http://www.modernhealthcare.com/article/20170913/NEWS/170919942
What’s behind the renewed enthusiasm in the Democratic Party for Sen. Bernie Sanders’ single-payer healthcare bill? The GOP still controls both houses of Congress and the White House. The Affordable Care Act still faces an existential crisis.
Unless something is done in the next few weeks to shore up the exchanges for 2018 and reverse HHS’ mean-spirited efforts to undermine enrollment, the enormous progress made over the past four years—last week the Census Bureau announced the nation’s uninsured rate had dropped sharply over that period to 8.8%—will begin to reverse. For those desperately working to avert the immediate danger, single-payer advocacy is a distraction.
Unfortunately, the logic of contemporary politics made the current push for single-payer inevitable. President Donald Trump and the tea party set the table. They proved that in a populist moment, extreme positions that cater to a sliver of the electorate are a viable path to electoral success.
Expect left-wing challengers supporting single-payer to win numerous Democratic House and Senate primaries next spring. A wave election typical of first-term, off-year elections will lead to a single-payer caucus in the next Congress with as much power as the tea party caucus had after the wave of election of 2010.
Single-payer looms as their threat. If you destroy President Barack Obama’s grand compromise-his eponymous plan relied on private insurers and preserved the employer-based system- the fire next time will get rid of both.
Unlike the tea party, single-payer advocates have history on their side. The U.S. over the last half century has moved inexorably toward universal coverage: Medicare and Medicaid; the Children’s Health Insurance Program; the ACA. It will get there one way or another.
Sanders asked the right question in his op-ed last week in the New York Times. “Do we, as a nation, join the rest of the industrialized world and guarantee comprehensive health care to every person as a human right?”
Polls now report growing support for single-payer health insurance. When asked if the government has the responsibility to guarantee access to healthcare for all Americans, nearly 60% answer yes. In other words, a clear majority of Americans now say yes to Sanders’ question.
It’s not just a human-rights issue. Universal access through universal insurance coverage is a necessary if insufficient component of getting healthcare costs under control. It is also a building block for restoring the nation’s economic competitiveness, especially in areas of the country suffering from a prolonged decline. No region can thrive unless it has a well-educated, healthy workforce.
Industrialized countries diverged in how they achieved universal coverage. Some chose a government-funded, single-payer system. Others chose well-regulated private insurers. Still others chose a combination of the two.
The U.S., because its employers used health benefits to get around World War II’s wage-and-price controls, accidentally chose a mixed system. It was the erosion of the employer-based system that led to Obamacare.
Sanders and his 15 Senate co-sponsors propose to eliminate the employer-based system entirely. He would gradually expand Medicare to cover everyone over four years.
The legislation is silent on how to transfer the $1.1 trillion spent by employers on health insurance to government coffers, necessary to defray the cost of his plan. He doesn’t address how he would counter the tremendous opposition that disrupting the existing system would draw from employers and their workers, including those in many unions.
Sanders decries the lack of progressive think tanks to come up with answers to those and other transition questions. But the problem isn’t the absence of good ideas. It’s the absence of fertile soil in which those ideas can grow.
That will change rapidly if Republicans succeed in repealing Obamacare, or undermine it and send the uninsured rate soaring again. That, and only that, will turn the single-payer threat into the last viable path to universal coverage.
WHY RETURNING TO A PRE-ACA MARKET ISN’T AN OPTION
http://www.managedhealthcareconnect.com/article/why-returning-pre-aca-market-isn-t-option
After the recent failed attempts to repeal the Affordable Care Act (ACA), it is anyone’s guess as to what comes next. Tax reform and infrastructure now appear to have moved ahead of health care on the legislative agenda—leaving the ACA largely out of lawmakers’ hands, and the Department of Health and Human Services (HHS) at the helm.
The President has implied that the federal government might halt federal payments to insurance companies meant to provide financial assistance to consumers who qualify for subsidies if they purchase health insurance on the ACA exchange. So far that has not happened. In a recent appearance on ABC’s “This Week” Sunday newsmagazine, HHS Secretary Tom Price, MD, said that he and his team are combing through the specifics of the ACA law, “asking the question, ‘does this help patients or does it harm patients? Does it increase costs or does it decrease costs?’”
There are more than 1400 instances in the law where the HHS Secretary has discretion to make changes, making the HHS the most likely source for any forthcoming health reform.
Republicans generally favor pushing more decision-making down to the states, and offering more choice to consumers. Dr Price has talked up a provision drafted by Senator Ted Cruz (R-Texas) that was included in the Senate’s plan. It would have given consumers the choice to purchase insurance that does not meet the ACA’s standard of the essential health benefits, but instead meets a given State’s definition of which service it deems essential. Coupled with the ability to grant state waivers for changes to the current law, many have suggested this could lead to consumers purchasing plans that do not cover most services.
“Dusting Off” The Old Way
The so-called Consumer Freedom Option is strongly opposed by the nation’s largest health insurers, which seemed to bewilder Secretary Price.
“It’s really perplexing, especially from the insurance companies, because all they have to do is dust off how they did business before Obamacare,” he said during the This Week interview. It is “exactly the kind of process that has been utilized for decades.”
Even though the Cruz provision went down with the rest of the Senate bill in July, it is not unreasonable to wonder if Secretary Price might try to figure out how to offer low-cost “skinny plans.” Or if Congress might do that same if and when health care moves back into the limelight.
This begs two questions:
- Can the United States ever go back to the way health insurance worked before the ACA, dusting things off, as Secretary Price suggested?
- Can selling insurance inside and outside of the ACA—as the Cruz provision envisioned—work?
Most industry experts offer a resounding “no” to both questions. As we have reported previously, it is difficult to take benefits away once they are given. For that reason, there is consensus that the ACA in some form or fashion is here to stay. There is also near universal agreement that certain parts of the ACA—notably the exchanges—need work. But experts also point out that provisions like Sen Cruz’s, that propose parallel systems where different rules apply, will not improve the exchanges, and indeed will likely hasten the so-called death spiral.
AHIP Objects, Actuaries Agree
In a July letter to Senate leaders, America’s Health Insurance Plans (AHIP) pointed out that even though the Cruz provision calls for a single risk pool, such a pool would be established “in name only. In fact, it creates two systems of insurance for healthy and sick people.”
A paper published this year by the American Academy of Actuaries, reinforces this claim.
“If insurers were able to compete under different issue, rating, or benefit coverage requirements, it could be more difficult to spread risks in the single risk pool…. Changes to market rules, such as increasing flexibility in cost-sharing requirements, could require only adjustments to the risk adjustment program. Other changes, such as loosening or eliminating the essential health benefit requirements, could greatly complicate the design and effectiveness of a risk adjustment program, potentially weakening the ability of the single risk pool to provide protections for those with preexisting conditions.”
Such a system, according to the paper, would effectively create two risk pools, and premiums in the ACA plans would be much higher than in those not subject to ACA regulations, leading to a destabilized ACA market. Moreover, things would get worse if people were allowed to move between plans depending on their health status.
Making the Problems Worse
The experts we spoke with agreed, citing the potential for confusion and flawed benefit design. Additionally, it does not adequately address the ACA exchange problems, and indeed may exacerbate them.
“The Cruz amendment would not likely achieve anything other than allowing young/healthy individuals to purchase cheaper, inadequate coverage at a lower price,” David Marcus, director of employee benefits at the National Railway Labor Conference, explained. “It would generally do nothing to lower premiums for ACA-compliant coverage.”
Gary Owens, MD, president of Gary Owens Associates, a medical management and pharmaceutical consultancy firm, implied that Cruz’s plan is a half-baked solution that most would have a difficult time navigating.
“This seems to just one more attempt to cobble together a solution to address the issue of healthcare access and coverage,” he said. “It would probably create more confusion for consumers about which plan is appropriate for their needs.”
Norm Smith, president of Viewpoint Consulting, Inc, which surveys managed markets decision-makers for the pharmaceutical industry, concurred.
“Many of the people buying these plans would not be able to define what’s covered, and what’s not,” he said. “Plans would be difficult for state insurance commissions to control without standardized benefit design.” He added that ACA plans would be crippled as younger, healthier people leave in favor of non-ACA coverage.
F Randy Vogenberg, PhD, RPh, principal at the Institute for Integrated Healthcare, said that the Cruz approach is a tepid response to what he sees as failure on the ACA exchanges.
“It has no merit because it does not address the need to change from the current exchange products,” he explained.
More Choice or Inadequate Coverage?
Proponents cite the fact that skinny plans give more choice to consumers, and that free-market principles are needed, vs increased government intervention. Mr Smith reminded us that the ACA—which is based on the Romney plan that became law in Massachusetts—already contains free-market components. For that reason, he said that introducing more choice could work in theory. However, in practice, “with the level of medical insurance literacy being so low, I’m not sure most members will understand what they are buying.”
Mr Marcus added that “The marketplace is already designed to have market principals, though the insurance that is available through [it] is limited to certain types of coverage. Offering more choice means certain people can get cheaper plans, but those cheaper plans are generally inadequate methods of protecting against health costs.”
Dr Owens explained that health reform will take much more than simply going back to the way insurance was sold in the 1990s, or tacking piecemeal amendments onto the ACA one after the other.
“Trying to glue on a piecemeal solution is not the answer,” he said. “Congress needs to drop the partisan approaches, put together a real working group that will take the needed time and use the available expertise to develop a comprehensive plan that takes the ACA to the next level.”
New Consumer Expectations
In the end, a big reason that insurers cannot simply dust off their plans from the past may be due to customer preference. Consumers often feel hamstrung when it comes to buying appropriate, affordable coverage. Yet they possess more power than many believe, as evidenced by the backlash Washington lawmakers have faced at local town hall meetings. This, in large part, led to the downfall of ACA repeal efforts.
The term “pre-existing conditions” is now a part of almost every health consumer’s lexicon, and people do not expect to be shut out of the market or forced to buy an exorbitantly expensive plan just because they have such a condition. The ACA appears to have cemented that mindset.
Dr Owens explained that insurers are more eager to work within the already established system of regulations, as opposed to wading into uncharted regulations.
“I don’t think the insurers want to increase the complexity of the marketplace,” he said.
Mr Smith agreed, adding that there would need to be “an awful lot of explaining before members knew what they were buying.”
“Going back just doesn’t make sense,” Mr Marcus noted. “Insurance carriers have spent huge sums of money developing systems to comply with the ACA. Profits at the largest carriers are the highest they have ever been. Insured individuals now have an expectation for ACA market reforms to be continued, but the concept behind the Cruz amendment would not change that.”
Additionally, the health insurance industry as a whole is probably concerned about payers who would choose to sell substandard plans outside of the ACA exchanges. Consumers would be left “in a bind when they need to access coverage,” Dr Owens said, which would not reflect well on the industry. — Dean Celia
HENRY KOTULA 