HOSPITALS SHOULD BE BRACING FOR SITE-NEUTRAL PAYMENTS

https://www.healthleadersmedia.com/finance/hospitals-should-be-bracing-site-neutral-payments

Even if the Trump administration were to delay its proposed site-neutral payments policy for outpatient facilities another year or longer, the political debate isn’t going away.


KEY TAKEAWAYS

Prominent hospital groups have said the rule, as proposed, would be illegal.

Lawmakers from both sides of the aisle in both chambers of Congress have voiced opposition.

Hospitals should do their long-term budgeting and strategizing with site-neutrality in mind.

A controversial proposal to cut reimbursement rates for hospital outpatient departments could be finalized this week if the Centers for Medicare & Medicaid Services hits its target date to publish the final rule.

The proposed change to the Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System unveiled last July has drawn criticism from the American Hospital Association (AHA), America’s Essential Hospitals (AEH), lawmakers in both houses of Congress, and others who contend the so-called “site-neutral” payment policies fail to account for the added burden hospital-owned facilities shoulder.

Both AHA and AEH said in formal comments last month that the OPPS/ASC proposal for 2019 appears to be illegal. And lawmakers raised related concerns in two separate letters to CMS Administrator Seema Verma, suggesting the proposal flouts congressional intent.

A bipartisan group of 48 senators signed a letter last month urging CMS to rethink its approach, and a bipartisan group of 138 representatives followed suit this month with a letter of their own.

The political pressure could very well leave an imprint on the final version of the rule, which has been under review by the Office of Management and Budget since October 10. A spokesperson for CMS told HealthLeaders that the agency would not speculate on the potential outcome of the review process, reiterating the agency’s plan to publish the final version on or about Thursday, November 1.

But even if the Trump administration were to postpone the site-neutral payments policy another year or longer, hospitals should still be preparing for site-neutrality, since this political debate will play itself out over the next several years one way or another, says Greg Hagood, a senior managing director with the financial advisory firm SOLIC Capital.

That preparation for site-neutrality should include an ambulatory strategy with investments in outpatient settings, Hagood said, with a word of caution for hospitals and health systems.

“I think they need to do their budgeting, though, with an eye toward the fact that certain areas that have historically been anchors to the hospital—whether that’s the emergency room, cardiac care, or some of these hospital outpatient departments—are likely to see diminished margins,” he said.

Basing a budget around more-conservative revenue estimates for these service lines could prompt hospitals to rationalize their cost structures or even adjust their infrastructure, such as by reducing their number of clinics or inpatient beds, Hagood said.

Although the concept of site-neutrality “makes a ton of sense” on the surface, there’s also a complex history in how American reimbursement models have evolved over the past few decades, and hospitals provide expensive services that other outpatient facilities often don’t, such as indigent care, Hagood said. Switching to a site-neutral system would have “a very economically disruptive impact on a lot of large health systems,” he added.

The debate gains another layer of intrigue when you consider how any action taken by lawmakers will be perceived by their constituents.

“If you want to make a congressman vulnerable,” Hagood said, “you’ll say he was supportive of a policy that results in a closure of a hospital in your district.”

 

 

Why Wealth Is Determined More by Power Than Productivity

Why Wealth Is Determined More by Power Than Productivity

According to a new OECD working paper, Britain is one of the wealthiest countries in the world. Net wealth is estimated to stand at around $500,000 per household – more than double the equivalent figure in Germany, and triple that in the Netherlands. Only Luxembourg and the USA are wealthier among OECD countries.

On one level, this isn’t too surprising – Britain has long been a wealthy country. But in recent decades Britain’s economic performance has been poor. Decades of economic mismanagement have left the UK lagging far behind other advanced economies. British workers are now 29% less productive than workers in France, and 35% less than in Germany. How can this discrepancy between high levels of wealth and low levels of productivity be explained?

The process of how wealth is accumulated has been subject of much debate throughout history. If you pick up an economics textbook today, you’ll probably encounter a narrative similar to the following: wealth is created when entrepreneurs combine the factors of production – land, labour and capital – to create something more valuable than the raw inputs. Some of this surplus may be saved, increasing the stock of wealth, while the rest is reinvested in the production process to create more wealth.

How the fruits of wealth creation should be divided between capital, land and labour has been subject of considerable debate throughout history. In 1817, the economist David Ricardo described this as “the principal problem in political economy”.

Nowadays, however, this debate attracts much less attention. That’s because modern economic theory has developed an answer to this problem, called ‘marginal productivity theory’. This theory, developed at the end of the 19th century by the American economist John Bates Clark, states that each factor of production is rewarded in line with its contribution to production. Marginal productivity theory describes a world where, so long as there is sufficient competition and free markets, all will receive their just rewards in relation to their true contribution to society. There is, in Milton Friedman’s famous terms, “no such thing as a free lunch”.

The aim was to develop a theory of distribution that was based on scientific ‘natural laws’, free from political or ethical considerations. As Bates Clark wrote in his seminal book, ‘The Distribution of Wealth’:

“[i]t is the purpose of this work to show that the distribution of income to society is controlled by a natural law, and that this law, if it worked without friction, would give to every agent of production the amount of wealth which that agent creates”.

Seen in this light, wealth accumulation is a positive sum game – higher levels of wealth reflect superior productive capacity, and people generally get what they deserve. There is some truth to this, but it is only a very small part of the picture. When it comes to how wealth is created and distributed, many other forces are at work.

Wealth, property, and plunder

The measure of wealth used by the OECD is ‘mean net wealth per household’. This is the value of all of the assets in a country, minus all debts. Assets can be physical, such as buildings and machinery, financial, such as shares and bonds, or intangible, such as intellectual property rights.

But something can only become an asset once it has become property – something that can be alienated, priced, bought and sold. What is considered as property has varied across different jurisdictions and time periods, and is intimately bound up with the evolution of power and class relations.

For example, in 1770 wealth in the southern United States amounted to 600% of national income – more than double the equivalent figure in the northern United States. This stark difference in wealth can summed up by one word: slavery.

For white slave owners in the South, black slaves were physical property – commodities to be owned and traded. And just like any other type of asset, slaves had a market price. As the below chart shows, the appalling scale of slavery meant that enslaved people were the largest source of private wealth in the southern United States in 1770.

When the United States finally abolished slavery in 1865, people who had formerly been slaves ceased to be counted as private property. As a result, slaveowners lost what had previously been their prized possessions, and overnight over half of the wealth in the southern US essentially vanished. All of a sudden, the southern states were no longer “wealthier” than their northern neighbours.

But did the southern states really become any less wealthy in any meaningful sense? Obviously not – the amount of labour, capital and natural resources remained the same. What changed was the rights of certain individuals to exercise an exclusive claim over these resources.

But the wealth that had been generated by slave labour did not disappear, and it wasn’t only the USA that benefitted from this. Many of Britain’s major cities and ports were built with money that originated in the slave trade. Several major banks, including Barclays and HSBC, can trace their origins to the financing of the slave trade, or the plundering of other countries’ resources. Many of Britain’s great properties, which today make up a significant proportion of household wealth, were built on the back of slave wealth. Even today, many millionaires (including many politicians) can trace some of their wealth to the slave trade.

The lesson here is that aggregate wealth is not simply a reflection of the process of accumulation, as theory tends to imply. It is also a reflection of the boundaries of what can and cannot be alienated, priced, bought and sold, and the power dynamics that underpin them. This is not just a historical matter.

Today some goods and services are provided by private firms on a commodified basis, whereas others are provided socially as a collective good. This can often vary significantly between countries. Where a service is provided by private firms (for example, healthcare in the USA), shareholder claims over profits are reflected in the firm’s value – and these claims can be bought and sold, for example on the stock market. These claims are also recorded as financial wealth in the national accounts.

However, where a service is provided socially as a collective good (such as the NHS in the UK), there are no claims over profits to be owned and traded among investors. Instead, the claims over these sectors are socialised. Profits are foregone in favour of free, universal access. Because these benefits are non-monetary and accrue to everyone, they are not reflected in any asset prices and are not recorded as “wealth” in the national accounts.

A similar effect is observed with pension provision: while private pensions (funded through capital markets) are included as a component of financial wealth in the OECD’s figures, public pensions (funded from general taxation) are excluded. As a result, a country that provides generous universal public pensions will look less wealthy than a country that rely solely on private pensions, all else being equal. The way that we measure national wealth is therefore skewed towards commodification and privatisation, and against socialisation and universal provision.

Capital gains, labour losses

The amount of wealth does not just depend on the number of assets that are accumulated – it also depends on the value of these assets. The value of assets can go up and down over time, otherwise known as capital gains and losses. The price of an asset such as a share in a company or a physical property reflects the discounted value of the expected future returns. If the expected future return on an asset is high, then it will trade at a higher price today. If the expected future return on an asset falls for whatever reason, then its price will also fall.

Marginal productivity theory states that each factor of production will be rewarded in line with its true contribution to production. But although presented as an objective theory of distribution, marginal productivity theory has a strong normative element. It says nothing about the rules and laws that govern the ownership and use of the factors of production, which are essentially political variables. For example, rules that favour capitalists and landlords over workers and tenants, such as repressive trade union legislation and weak tenants’ rights, increase returns on capital and land. All else being equal, this will translate into higher stock and property prices, which will increased measured wealth. In contrast, rules that favour workers and tenants, such as minimum wage laws and rent controls, reduce returns on capital and land. This in turn will translate into lower stock and property prices, and lower paper wealth.

Importantly, in both scenarios the productive capacity of the economy is unchanged. The fact that wealth would be higher in the former case, and lower in the latter case, is a result of an asymmetry between how the claims of capitalists and landlords are recorded, and how the claims of workers and tenants are recorded. While future returns to capital and land get capitalised into stock and property prices, future returns to labour – wages – do not get capitalised into asset prices. This is because unlike physical and financial assets, people do not have an “asset price”. They cannot become property. As a result, it is possible for measured wealth to increase simply because the balance of power shifts in favour of capitalists and landowners, allowing them to claim a larger slice of the pie at the expense of workers and tenants.

To the early classical economists, this kind of wealth – attained by simply extracting value created by others ­­– was deemed to be unearned, and referred to it as ‘economic rent’. However, ever since neoclassical economics replaced classical economics as the dominant school of thinking in the late 19th century, economic rent has been increasingly marginalised from economic discourse. To the extent that it is acknowledged, it is usually viewed as being peripheral to the story of wealth accumulation, resulting from  ‘market frictions’, such as monopsony and asymmetric information, which give rise to certain instances of ‘market power’. For the most part, economists have tended to focus on the acts of saving and investment which drive the real production process. But on closer inspection, it is clear that economic rent is far from peripheral. Indeed, in many countries it has been the main story of changing wealth patterns.

To see why, let’s return to the OECD wealth statistics. Recall that net wealth per household in Britain is more than double what it is in Germany, even though Germany is far more productive than the UK. This can partly be explained by comparing the power dynamics associated with each factor of production.

Let’s start with land: Germany has among the strongest tenant protection laws in Europe, and many German cities also impose rent controls. This, along with a banking sector that favours real economy lending over property lending, means that Germany has not experienced the rampant house price inflation that the UK has. Remarkably, the house price-to-income ratio is lower in Germany today than it was in 1995, while in the UK it has nearly tripled over the same time period. The fact that houses are not lucrative financial assets, and renting is more secure and affordable, means that the majority of people choose to rent rather than own a home in Germany – and therefore do not own any property wealth.

In Britain, the story couldn’t be more different. Over the past five decades Britain has become a property owners’ paradise, as successive governments have sought to encourage people onto the property ladder. Taxes on land and property have been removed, and subsidies for homeownership introduced. The deregulation of the mortgage credit market in the 1980s meant that banks quickly became hooked on mortgage lending – unleashing a flood of new credit into the housing market. Rent controls were abolished, and the private rental market was deregulated. Today tenant protection is weaker than almost anywhere else in Europe. Meanwhile, the London property market has served as a laundromat for the world’s dirty money. As Donald Toon, head of the National Crime Agency, has described: “Prices are being artificially driven up by overseas criminals who want to sequester their assets here in the UK”.

The result has been an unprecedented house price boom. Since 1995, skyrocketing house prices have increased value of Britain’s housing stock by over £5 trillion – accounting for three quarters of all household wealth accumulated over the same period. While this has been great news for property owners, it has been disastrous for tenants. As I’ve written elsewhere, the driving force behind rising house prices has been rapidly escalating land prices, and we have known since the days of Adam Smith and David Ricardo that land is not a source of wealth, but of economic rent. The trillions of pounds of wealth amassed through the British housing market has mostly been gained at the expense of current and future generations who don’t own property, who will see more of their incomes eaten up by higher rents and larger mortgage payments.

So while German property owners have not benefited from skyrocketing house prices in the way that they have in Britain, the flipside is that German renters only spend 25% of their incomes on rent on average, while British renters spend 40%. The former is captured in the OECD’s measure of wealth, while the discounted value of the latter is not.

Now let’s look at capital. In the UK and the US, the goal of the firm has traditionally been to maximise shareholder value. In Germany however, firms are generally expected to have regard for a wider range of stakeholders, including workers. This has led to a different culture of corporate governance, and different power dynamics between capital and labour.

Large companies in Germany must have worker representatives of boards (referred to as ‘codetermination), and they are also required to allow ‘works councils’ to represent workers in day-to-day disputes over pay and conditions. The evidence indicates that this system has led to higher wages, less short-termism, greater productivity, even higher levels of income equality. The quid pro quo is that it also tends to result in lower capital returns for shareholders, as workers are able to claim more of the surplus. This in turn means that German firms tend to be valued less than their British counterparts on the stock market, which contributes to lower levels of financial wealth.

None of this means that Germany is poorer than Britain. Instead, it just reflects the fact that German capitalists and landowners have less bargaining power than they do in the UK, while workers and tenants have more power. While lower shareholder returns and house prices are reflected in the OECD’s measure of wealth, better pay and conditions and lower rents are not.

Conclusion

All statistics tell a story, but stories can be told from different perspectives. Embedded in the definitions of all economic statistics are value judgements about what is desirable and what is undesirable, which in turn shape the way we think about the economy. At the moment, the way we measure the wealth of nations mainly reflects the fortunes of capitalists and landowners rather than workers and tenants. Britain looks wealthier than Germany on paper, but this does not reflect the lived reality for most people. While it’s important not to overstate the extent to which statistics can influence the real world, this is important for at least three reasons.

Firstly, it illustrates how seemingly objective metrics often have ideological assumptions baked into them. While there is already a well-established literature on alternatives to GDP, many economic metrics are used in economic analysis and policy appraisal without any critical appraisal of their underlying ideological assumptions. This needs to change.

Second, it highlights how paper wealth has in many places become decoupled from productive capacity, and how conflating the two can be highly misleading. This is particularly the case where zero sum rentier activity is widespread, as in the case of Britain. Such discrepancies raise the question of whether the way that we currently measure wealth is really the most sensible.

But most importantly, it illustrates that the distribution of wealth has little to do with contribution or productivity, and everything to do with politics and power. As J.W. Mason states: “It’s bargaining power, it’s politics, all the way down.”

For economists who see their discipline as a ‘value free’ science which is separate from politics, this is uncomfortable territory. But if the aim is to understand the economy as it really exists, then analysing power beyond the narrow concept of ‘market power’ is essential. Among other things, this means grappling with the power dynamics that underpin ownership and property relations, as well as those that that drive inequalities between different social groups and identities.

It’s been 200 years since David Ricardo described the “principal problem” of political economy. Perhaps it’s time to revisit it.

 

 

 

Covered CA enrollment expected to drop as penalty ends

https://www.modbee.com/living/health-fitness/article220347880.html

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Covered California’s fall enrollment period will show whether peace of mind is a motivation for people to keep their health insurance next year.

Last year, Congress passed legislation that in 2019 erases the federal tax penalty for people without coverage.

Without the threat of a penalty, Covered California, the state’s health exchange, estimates that 12 percent of its customers, or 162,000 residents, will leave the program and an additional 100,000 who purchase insurance from brokers in the state will discontinue coverage.

Affordable Care Act supporters believe there are sound reasons for the 1.4 million consumers in the program to stay insured — to protect themselves against crushing medical bills at rates subsidized by the federal government.

Almost 70,000 residents in a five-county pricing region, including Stanislaus, San Joaquin, Merced, Mariposa and Tulare counties, are covered on the exchange and 95 percent of them receive help with monthly premiums. About 18,000 are covered in Stanislaus County.

“Certainly it’s possible some will roll the dice and decide to go without coverage,” James Scullary, a Covered California spokesman, said Friday. “People generally want health insurance. They want to have that peace of mind of coverage in case of an injury or illness.”

The anticipated departure of some consumers from the pool accounts for part of an 8.7 percent average rate increase next year for Obamacare plans offered by 11 insurers in California. On average, those insurers tacked an extra 3.5 percent onto next year’s rates due to projected costs of serving a smaller, less healthy customer base when the tax penalty ends.

Individuals and families whose premiums are subsidized will see small increases because higher premiums are triggers for larger federal tax credits. It will serve to pass $250 million in additional costs to the federal government. Individuals earning between $16,754 and $48,560 a year are eligible for subsidized rates and the same applies to a family of four with income between $34,638 and $100,400 a year.

Those not eligible for subsidies will be stung by the rate increases, projected at almost 7 percent in the five-county region. A state bill to help middle-income households buy costly insurance on the individual market failed to pass this year.

The enrollment period for 2019 opened last week and runs through Jan. 15. The enrollment deadline is Dec. 15 for coverage to take effect Jan. 1.

A 40-year-old adult earning $35,000 a year can purchase a standard Silver plan for monthly costs ranging from $187 to $376, according to Covered California’s “shop and compare” online tool. Anthem Blue Cross, Kaiser Permanente, Blue Shield of California and HealthNet are the four insurance carriers offering the metal tier plans (Bronze to Platinum) in this region.

For a family of four with annual income of $62,500, monthly costs for Silver coverage will range from $254 to $625, depending on what plan is chosen. In that scenario, the two children may be eligible for free or low-cost care through the Medi-Cal program and the parents could receive extra help for co-payments.

Some residents not eligible for subsidies settle for the skimpy Bronze coverage through Covered California. A 55-year-old with $60,000 annual income will pay from $535 to $821 a month for Bronze plans next year. The cheapest Bronze HMO requires 40 percent co-pays for primary care visits and generic drugs; the annual out-of-pocket maximum is $6,000.

Citing data from Covered California’s consumer pool, Scullary said that 1.2 million customers have needed some health care and 153,000 have been protected from claims ranging from $5,000 to $50,000. Scullary said 15,000 consumers were shielded from health care costs over $50,000 and 42 people had claims in excess of $1 million.

The state exchange will promote enrollment this fall through an advertising campaign and a bus tour beginning after the November election, the spokesman said. The agency has local partners and certified brokers across the state to assist consumers with choosing suitable plans.

Covered California has a Monday-to-Saturday customer service line at 800-300-1506. Enrollment information is available at www.coveredca.com.

 

 

 

What’s at Stake for Health Care in Your District This Midterm Election?

What’s at Stake for Health Care in Your District This Midterm Election?

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On November 6, 2018, Californians will head to the polls to vote for who will represent them in Congress. The outcome of races could have significant implications for health care in California and nationwide. Major policies at stake include the Affordable Care Act (ACA), the Medicaid program (called Medi-Cal in California), and protections for those with preexisting conditions.

What’s at stake for California?

  • 1.4 million Californians purchase coverage through Covered California, the health insurance marketplace established under the ACA. Close to 90% receive federal subsidies to help them afford their premiums.
  • 13.5 million Californians are covered by Medi-Cal.
  • 6.7 million Californians would have lost coverage by 2027 if the last attempt by Congress to repeal the ACA and cut Medicaid (through a proposal called Graham-Cassidy) had passed. It is widely anticipated that a future attempt to repeal the ACA would be modeled after Graham-Cassidy.
  • 550,000 fewer jobs would have been created in California by 2027 if Graham-Cassidy had passed.
  • 16.7 million nonelderly Californians are estimated to live with a preexisting condition.

What’s at stake in your district?

 

On the Rise – Out-of-Pocket Healthcare Spending in 2017

https://www.jpmorganchase.com/corporate/institute/report-on-the-rise.htm?utm_source=newsletter&utm_medium=email&utm_campaign=newsletter_axiosvitals&stream=top

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Leveraging financial transaction data, the JPMorgan Chase Institute provides a unique cash flow view of families’ healthcare out-of-pocket spending and financial burden. In 2017 we released the first estimates of out-of-pocket healthcare spending levels and burden at the state and county level from 2013 to 2016, from our JPMorgan Chase Institute Healthcare Out-of-pocket Spending Panel (JPMCI HOSP) data asset. In this new report, we describe enhancements to, and key findings from, the updated JPMCI HOSP data asset that includes the first available estimates of 2017 healthcare out-of-pocket spending trends, as well as a first-ever look at year-over-year trends at the state and county level and for different demographic groups.

Our key findings are:

Finding 1: Year-over-year growth in out-of-pocket healthcare spending levels accelerated since 2014 to 8.5 percent in 2017. The burden of healthcare spending as a percent of take-home income ticked up slightly.

Finding 2: In 2017 high-income families experienced the fastest growth in healthcare spending, while low-income families experienced the highest growth in healthcare spending burden.

Finding 3: In 2017, families in Utah spent the most on and were the most burdened by out-of-pocket healthcare spending, while families in California saw the highest growth in spending levels.

Finding 4: Out-of-pocket healthcare spending grew the most at hospitals and ‘other’ healthcare providers and decreased at drug stores for the third consecutive year.

 

 

Repeal of ACA on Republican agenda after midterms

https://www.healthcarefinancenews.com/news/repeal-aca-republican-agenda-after-midterms?mkt_tok=eyJpIjoiTldNeU1qQmpOMk14WXpRMyIsInQiOiJDSlRcL25VMHRkNTlLQzZqU1dERHJzWnFlUmR2MCtJcWNaT0VZVUprSWY4ejJ2a1ZlemRaZStIaVA4bWRIM3h6VlphdWJreDRwK1cwbjhNWnZ0WmFCeVQ3b2lTSTQ5Y1krdHFKQTdCQ1dPRDd2a1NOVDFBTG5ESWpNUnhQYzVvdWwifQ%3D%3D

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Repeal would end the ACA’s most popular provision, to cover those with preexisting conditions.

Republicans could try again to repeal the Affordable Care Act if they win enough seats in the midterm election this November, Senate Republican Leader Mitch McConnell said on Wednesday, according to Reuters.

WHY THIS MATTERS

Providers want to keep the ACA to minimize the cost of uncompensated care from treating individuals who have no insurance.

Insurers this year have turned around earlier losses and exits, expanding their footprint in the market and, in many cases, offering lowering premium rates for 2019.

Studies show most consumers like the ACA but remain confused about the healthcare law, with close to 80 percent unaware that open enrollment starts on November 1.

THE TREND

Republicans last year tried and failed to repeal the ACA. In another attempt to get rid of the individual and employer mandates for coverage, the GOP this summer introduced the “skinny” repeal in the Health Care Freedom Act.

On July 28, Senator John McCain cast the deciding vote when he joined two other Republican senators in voting down the skinny repeal of the ACA that the Congressional Budget Office said could result in 16 million more people becoming uninsured. Provider groups such as America’s Essential Hospitals and the American Medical Association, voiced their approval that the skinny repeal failed.

Republicans got rid of the individual and employer mandates in this year’s budget bill.

The Trump Administration also introduced a less expensive alternative to ACA plans in allowing consumers to buy short-term limited duration plans that offer coverage for up to a year and can be extended for three years. The short-term plans are not mandated by law, as are ACA plans, to cover pre-existing conditions and offer essential benefits.

THEIR TAKE

Republicans have long promised to end the ACA because they say it’s not working.

OUR TAKE

Republicans have been chipping away at Obamacare and the government has drastically cut funds to promote it, but at the same time, the Department of Health and Human Services has helped to stabilize the market. Most significantly, it has allowed insurers to silver load plans to apply full premium increases to silver plans in the ACA to make up for the loss of cost-sharing reduction payments that were eliminated by President Trump. Since nine out of 10 consumers get tax subsidies for buying plans, this move was essentially subsidized by the federal government.

Even if the GOP retains its majority this November, repeal of the ACA will be an uphill battle. It would end the ACA’s most popular provision to cover those with preexisting conditions.

President Trump tweeted on Friday his support of protecting those who have preexisting conditioins saying. “All Republicans support people with pre-existing conditions, and if they don’t, they will after I speak to them. I am in total support. Also, Democrats will destroy your Medicare, and I will keep it healthy and well!”

 

 

 

CMS announces new waiver flexibility in ACA market

https://www.healthcarefinancenews.com/news/cms-announces-new-waiver-flexibility-aca-market?mkt_tok=eyJpIjoiTldNeU1qQmpOMk14WXpRMyIsInQiOiJDSlRcL25VMHRkNTlLQzZqU1dERHJzWnFlUmR2MCtJcWNaT0VZVUprSWY4ejJ2a1ZlemRaZStIaVA4bWRIM3h6VlphdWJreDRwK1cwbjhNWnZ0WmFCeVQ3b2lTSTQ5Y1krdHFKQTdCQ1dPRDd2a1NOVDFBTG5ESWpNUnhQYzVvdWwifQ%3D%3D

 

States will have the ability to allow individuals to use ACA subsidies when buying short-term limited duration plans.

States are getting new flexibility in waivers to the Affordable Care Act, including being able to target ACA subsidies for individuals who want to buy short-term, limited duration plans, Centers for Medicare and Medicaid Services Administrator Seema Verma said today.

What is not flexible is protecting access to coverage to those with pre-existing conditions.

Verma gave no specifics on the types of waivers that will be considered, but said the agency was preparing to release a series of waiver concepts. More specifics are expected to be released in the coming weeks.

The policy goes into effect today but is expected to impact states next year, for the 2020 plan year.

IMPACT

The effect of the waivers will likely not be known until next year.

But the allowance of short-term insurance as an ACA alternative could have a more immediate effect as consumers choose plans during open enrollment starting November 1.

The Trump Administration this year extended the length of short-term plans from three months to one year, with an extension allowed for up to three years. Because these plans would not be obligated to cover the essential benefits mandated under the ACA, premiums are expected to be lower.

Opponents have said this would cause an exodus of healthy consumers from the traditional ACA market and rising prices for those left behind.

THE TREND

CMS has been taking credit for stabilizing the ACA market and lowering premiums through the use of waivers and by easing regulations.

For instance, reinsurance waivers have helped reduce premium costs, CMS said. To date, CMS has approved eight state waivers, and all but one have been a reinsurance waiver for states to develop high-risk pools to help pay the cost of high claims.

The reason for the lack of other approved waivers is due to the previous Administration limiting the types of state waiver proposals that the government would approve, CMS said.

The new Section 1332 waivers, called state relief and empowerment waivers, will allow states to “get out from under onerous rules of Obamacare,” Verma said.

WHAT ELSE YOU NEED TO KNOW

Under Section 1332 of the ACA, states can waive certain provisions of the law as long as the new state waiver plan meets specific criteria, or “guardrails,” that help guarantee people retain access to coverage that is at least as comprehensive and affordable as without the waiver; covers as many individuals; and is deficit neutral to the federal government.

The new waivers should aim to provide increased access to affordable private market coverage; encourage sustainable spending growth; foster state innovation; support and empower those in need; and promote consumer-driven healthcare, CMS said.

ON THE RECORD

“Now, states will have a clearer sense of how they can take the lead on making available more insurance options, within the bounds of the Affordable Care Act, that are fiscally sustainable, private sector-driven, and consumer-friendly,” said Health and Human Services Secretary Alex Azar.

“The Trump Administration inherited a health insurance market with skyrocketing premiums and dwindling choices,” said CMS Administrator Seema Verma. “Under the president’s leadership, the Administration recently announced average premiums will decline on the federal exchange for the first time and more insurers will return to offer increased choices.

“But our work isn’t done. Premiums are still much too high and choice is still too limited. This is a new day — this is a new approach to empower states to provide relief. States know much better than the federal government how their markets work. With today’s announcement, we are making sure that they have the ability to adopt innovative strategies to reduce costs for Americans, while providing higher quality options.”

 

Why the new ACA waivers matter

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As in-the-weeds as a revised waiver process sounds, the practical effects of what the Trump administration announced yesterday could add up to one of its most substantive blows yet against the Affordable Care Act.

The big picture: These changes will likely cause more separation of healthy and sick people, but only in states that avail themselves of these new options — creating another level of segmentation between red and blue states.

How it works: Under the Obama administration, states seeking a waiver from the ACA’s rules had to show that their alternatives would cover just as many people as the ACA, with insurance that’s just as robust, for the same cost. That’s why only 8 waivers have ever been granted.

  • But under the Trump administration’s approach, if the same number of people have access to ACA-level coverage, that’ll count — even if few of them actually choose it.
  • Likewise, “a waiver that makes coverage much more affordable for some people and only slightly more costly for a larger number of people would likely meet” the new standards, the formal policy guidance says.
  • States could, for example, seek a waiver that would let their residents apply the ACA’s premium subsidies to “short-term” insurance plans, even though those plans don’t meet the ACA’s requirements, including the mandate to cover people with pre-existing conditions.

Between the lines: The Trump administration has often treated the ACA’s exchanges as a de facto high-risk pool. And that’s the best prism through which to understand these latest changes.

  • These waivers will let states lean even further into new, non-ACA options for healthy people. That will likely increase premiums for ACA coverage. But because the vast majority of ACA enrollees are subsidized, they’ll be insulated from those costs.

There are limits to how far that dynamic can go, because states’ waivers still can’t add too much to the federal government’s costs. But that’s the basic dynamic at play here — and it’s one that will continue to move the larger individual market further and further away from the ACA.