Tag Archives: High Risk Pools

Editorial: It’s now or never to fix next year’s insurance exchange rates

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http://www.modernhealthcare.com/article/20170603/MAGAZINE/170609997/editorial-its-now-or-never-to-fix-next-years-insurance-exchange-rates

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As the ad hoc committee of 13 Republican senators rethinks the increasingly unpopular American Health Care Act, Congress and the administration face a more pressing question. Will they stabilize the individual insurance market for 2018?

Preliminary rate filings for next year suggest that some states are entering the first phases of the much-dreaded death spiral, where rising rates and declining enrollments feed on each other to climax in a collapsed market. Where last year it was mostly rural areas that suffered from a dearth of carriers offering exchange plans, major urban areas like Kansas City and Knoxville, Tenn., are now among the regions reporting no insurers interested in offering coverage.

Meanwhile, carriers are requesting double-digit rate hikes in many areas of the country. Increase requests as high as 50% have been reported.

Republicans blame the Affordable Care Act. But, in fact, blame rests squarely with the Trump administration and the Republican-controlled Congress, who’ve created tremendous uncertainty around the policies that make the ACA’s individual market work.

The biggest single problem is Congress’ failure to appropriate the $7 billion owed insurers for underwriting cost-sharing reductions for low-income plan purchasers. That affects about 7 million of the 13 million people who signed up for individual plans.

Last year, Congress also put a one-year hold on the surcharge on health insurance premiums that supports ACA subsidies. Without further action, the tax, which was slated to raise about $100 billion over the next decade, will go into effect in 2018.

From a budgetary perspective, the move is a wash. The increased tax collection will be offset by the increased subsidies given low-income people who buy plans. People who are unsubsidized—those most likely to be bitter opponents of Obamacare—will be hit dollar-for-dollar with the rate hike.

President Donald Trump​ also contributed to uncertainty over next year’s enrollment period. First, he halted media promotion of the 2017 open enrollment. Then, in February, he issued an executive order waiving the individual mandate, which is key to getting millions of younger, relatively healthy people into the individual market pool.

While Politico reported last month that the Internal Revenue Service didn’t carry out the president’s order this year, the atmospherics around these pronouncements will ensure that fewer people sign up for individual plans in 2018. Insurers are assuming they will be covering an older, sicker population, a surefire path to higher rates.

Last week, Bradley Wilson, CEO of Blue Cross and Blue Shield of North Carolina, dissected how these compounding uncertainties contributed to its request for a 22.9% rate hike. About half the increase came from the missing cost-sharing reduction subsidies; about a third from an expected increase in medical losses, driven by rising costs and a sicker pool; and the rest from the expected tax.

This Republican Congress and the administration could quickly solve these problems without sacrificing their political principles. The administration could signal it will enforce the mandate since it is still the law. Congress could appropriate the money for the cost-reduction subsidies. This would preserve the House’s lower court victory in its suit challenging the Obama administration’s lacking an appropriation.

And, in a nod to their goal of protecting people with pre-existing medical conditions, Congress could create a reinsurance program to cover the extraordinary expenses of high-cost patients in the individual market. Unlike state-run high-risk pools, which have never worked, a federally funded reinsurance program would preserve everyone’s access to health insurance in the individual market at affordable rates.

It’s up to Congress now. Insurers face a June 21 deadline for notifying HHS about participation in the exchanges, and final rates are due from states by Aug. 16; there’s not much time to act. We’ll soon find out if Trump and this Congress intend to deny millions of people access to affordable health insurance next year.

 

The ‘Kimmel test’ could be a good health care yardstick for the GOP

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The ‘Kimmel test’ could be a good health care yardstick for the GOP

Should the “Kimmel test” help shape the health care bill that the US Senate is now working on behind closed doors? Republican senators could easily use it to vet the bill while staying true to their conservative roots.

Last month, talk show host and comedian Jimmy Kimmel shared with his audience a story about his son, Billy, who had been born a few days earlier with a heart defect called the tetralogy of Fallot and needed open heart surgery at three days old.

“If your baby is going to die, and it doesn’t have to, it shouldn’t matter how much money you make,” pleaded Kimmel in an impassioned take on health insurance that has been viewed by millions.

Not long afterward, Republican Senator Bill Cassidy, a physician who represents Louisiana, said that any Republican health care legislation would need to pass the “Jimmy Kimmel test.” Morally and politically, Cassidy is right.

Every day in my work in a pediatric emergency department, I see firsthand that the Affordable Care Act, the law that the Republican House and Senate are determined to replace, saves lives. Before the ACA, children born with pre-existing conditions were often uninsurable, their families left to struggle with an unmanageable economic burden.

Kimmel thinks the solution is easy: “Don’t give a huge tax cut to millionaires like me and instead leave it [the ACA] how it is.” But the solution is far from easy.

As a physician, a conservative Republican, and a health insurance scholar, I believe that government intrusion into private insurance has had serious consequences. Families across America are paying thousands of dollars a year more in higher health insurance premiums. Insurers, which have been losing money, have started abandoning entire markets. The House of Representatives passed the American Health Care Act in early May, believing it had to do so to stabilize markets and reduce premiums. But the Congressional Budget Office finally reported that the AHCA strips away most protections for pre-existing conditions and pushes an estimated 23 million more Americans into being uninsured.

Can we Republicans pass the Kimmel test, improving on the AHCA while still ensuring the sustainability of American health care? Senate Republicans have expressed skepticism, but I believe we can. The key is to stay true to our roots by adhering to four conservative principles.

First, private markets must remain free. Healthy people will need to help pay for sick people — that’s how health insurance works — but they must be allowed to choose their own insurance. The ACA coerced the healthy into paying above-market rates for insurance, and so it prohibited the lower-premium catastrophic plans that make sense for most families.

Second, the poor should never pay for government benefits to the wealthy. The main way the ACA tries to help families with pre-existing conditions is by regulating insurance premiums, but that means its benefits are indiscriminate. The young and healthy, many of whom are struggling economically, pay more. The elderly, many of whom need help but some of whom are wealthy, pay less. We should use America’s progressive tax system, where the wealthy pay more in taxes, to implement a means-tested health insurance system that specifically helps the needy. Republicans don’t love taxes, but a hidden tax is worse than a visible one, and it is utter anathema that the ACA moves even a single dollar from the poor to the rich.

Third, redistribution must be transparent. The ACA mainly forces higher costs onto private insurance plans, which invisibly pass those costs to healthy consumers. Democrats may prefer this hidden tax politically, but to abide by conservative principles, a subsidy must come with a budget that can be seen, understood, and voted on.

Fourth, health insurance subsidies must be structured to reduce expenditures over time. Just as welfare should be a bridge to independence for individuals, subsidies should be a bridge to sustainability for the health care industry.

The ACA introduced some promising cost-reductions, like financial responsibility provisions for hospitals and limits on luxury plan tax deductions. The Senate needs to continue these efforts. Subsidized care must be adequate and compassionate, but it should insist on using generic drugs (when available) rather than brand-name ones, and it should not cover newly constructed hospitals or low-value services. Medicine must de-intensify, helping patients receive care at home instead of in hospitals when appropriate and using social workers to meet social needs. We also need to help subsidized patients take more responsibility for their health — showing up for appointments, taking prescribed medications, and, if needed, quitting smoking and receiving treatment for addiction.

In my view, the best way to accomplish these four goals would be through either a federally funded expansion of Medicaid or a federally run high-risk pool, which would offer families a means-tested option to buy in once medical bills reach a certain point. Such a plan would intentionally have high deductibles and copays, but it would offer extra assistance to needy families. The private insurance market would be free to compete on price and quality, innovating new ways to deliver value.

I am not writing to advocate for any specific plan. Instead, I offer conservative principles as a yardstick: Does the program provide compassionate, adequate coverage to the sick? Is it transparent, fair, and sustainable? Are the healthy still free to choose their own insurance?

Republicans can craft sensible, conservative subsidies to protect our most vulnerable citizens while also preventing hidden taxes and blank checks. Kimmel is right: No parents should have to choose between bankruptcy and saving their child’s life. Nor does our nation have to choose between fiscal irresponsibility and compassion for our most vulnerable.

In Washington state, a healthcare repeal lesson learned the hard way

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http://www.latimes.com/politics/la-na-pol-obamacare-washington-state-20170531-story.html

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Republicans in the state of Washington didn’t wait long in the spring of 1995 to fulfill their pledge to roll back a sweeping law expanding health coverage in the state.

Coming off historic electoral gains, the GOP legislators scrapped much of the law while pledging to make health insurance affordable and to free state residents from onerous government mandates.

It didn’t work out that way: The repeal left the state’s insurance market in shambles, sent premiums skyrocketing and drove health insurers from the state. It took nearly five years to repair the damage.

Two decades later, the ill-fated experiment, largely relegated to academic journals, offers a caution to lawmakers at the national level as Republicans in the U.S. Senate race to write a bill to repeal and replace the federal Affordable Care Act.

“It’s much easier to break something,” said Pam MacEwan, who served on a Washington state commission charged with implementing the law in the mid-1990s and now oversees the state insurance market there. “It’s more difficult to put Humpty Dumpty back together again. … And that’s when people get hurt.”

The nonpartisan Congressional Budget Office echoed that warning last week, when it concluded that the healthcare bill passed by the House last month would destabilize insurance markets in a sixth of the country and nearly double the number of people without health insurance over the next decade.

Senate Republican leaders contend that their legislation will be different. “We’re working to lower the costs and give people more personal, individual freedom,” Sen. John Barrasso (R-Wyo.) said last week.

There were similar assurances in the Washington statehouse when legislators there began to pull apart the Washington Health Services Act in the mid-1990s.

 

 

Divisions emerge in the Senate on pre-existing conditions

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Divisions emerge in the Senate on pre-existing conditions

Divisions emerge in the Senate on pre-existing conditions

Senate Republicans are showing early divisions over what to do about ObamaCare’s protections for people with pre-existing conditions.

Some conservatives, including Sen. Mike Lee (R-Utah), want to simply repeal those provisions and other ObamaCare regulations and leave them up to the states.

But advocates of a more centrist approach, like Sen. Bill Cassidy (R-La.), are speaking out in favor of pre-existing condition protections and endorsing a “Jimmy Kimmel test” for the bill, where no one can be denied coverage.

Other senators are exploring a middle ground where states would have to automatically enroll people in health insurance before they could get a waiver for the regulations, though conservatives object to that idea as Washington overreach.

The disagreements over what to do about preexisting conditions point to the larger difficulty facing Senate Republicans as they seek to find consensus on a host of contentious issues in the healthcare bill.

Pre-existing Conditions and Medical Underwriting in the Individual Insurance Market Prior to the ACA

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Pre-existing Conditions and Medical Underwriting in the Individual Insurance Market Prior to the ACA

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Before private insurance market rules in the Affordable Care Act (ACA) took effect in 2014, health insurance sold in the individual market in most states was medically underwritten.1  That means insurers evaluated the health status, health history, and other risk factors of applicants to determine whether and under what terms to issue coverage. To what extent people with pre-existing health conditions are protected is likely to be a central issue in the debate over repealing and replacing the ACA.

This brief reviews medical underwriting practices by private insurers in the individual health insurance market prior to 2014, and estimates how many American adults could face difficulty obtaining private individual market insurance if the ACA were repealed or amended and such practices resumed.  We examine data from two large government surveys: The National Health Interview Survey (NHIS) and the Behavioral Risk Factor Surveillance System (BRFSS), both of which can be used to estimate rates of various health conditions (NHIS at the national level and BRFSS at the state level). We consulted field underwriting manuals used in the individual market prior to passage of the ACA as a reference for commonly declinable conditions.

 

Pre-ACA Market Practices Provide Lessons for ACA Replacement Approaches

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Pre-ACA Market Practices Provide Lessons for ACA Replacement Approaches

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Significant changes to the Affordable Care Act (ACA) are being considered by lawmakers who have been critical of its general approach to providing coverage and to some of its key provisions. An important area where changes will be considered has to do with how people with health problems would be able to gain and keep access to coverage and how much they may have to pay for it.  People’s health is dynamic. At any given time, an estimated 27% of non-elderly adults have health conditions that would make them ineligible for coverage under traditional non-group underwriting standards that existed prior to the ACA. Over their lifetimes, everyone is at risk of having these periods, some short and some that last for the rest of their lives.

One of the biggest changes that the ACA made to the non-group insurance market was to eliminate consideration by insurers of a person’s health or health history in enrollment and rating decisions.  This assured that people who had or who developed health problems would have the same plan choices and pay the same premiums as others, essentially pooling their expected costs together to determine the premiums that all would pay.

Proposals for replacing the ACA such as Rep. Tom Price’s Empowering Patients First Act and Speaker Paul Ryan’s “A Better Way” policy paper would repeal these insurance market rules, moving back towards pre-ACA standards where insurers generally had more leeway to use individual health in enrollment and rating for non-group coverage.1  Under these proposals, people without pre-existing conditions would generally be able to purchase coverage anytime from private insurers.  For people with health problems, several approaches have been proposed: (1) requiring insurers to accept people transitioning from previous coverage without a gap (“continuously covered”); (2) allowing insurers to charge higher premiums (within limits) to people with pre-existing conditions who have had a gap in coverage; and (3) establishing high-risk pools, which are public programs that provide coverage to people declined by private insurers.

The idea of assuring access to coverage for people with health problems is a popular one, but doing so is a challenge within a market framework where insurers have considerable flexibility over enrollment, rating and benefits.  People with health conditions have much higher expected health costs than people without them (Table 1 illustrates average costs of individuals with and without “deniable” health conditions). Insurers naturally will decline applicants with health issues and will adjust rates for new and existing enrollees to reflect their health when they can.  Assuring access for people with pre-existing conditions with limits on their premiums means that someone has to pay the difference between their premiums and their costs.  For people enrolling in high-risk pools, some ACA replacement proposals provide for federal grants to states, though the amounts may not be sufficient.  For people gaining access through continuous coverage provisions, these costs would likely be paid by pooling their costs with (i.e., charging more to) other enrollees.  Maintaining this pooling is difficult, however, when insurers have significant flexibility over rates and benefits.  Experience from the pre-ACA market shows how insurers were able to use a variety of strategies to charge higher premiums to people with health problems, even when those problems began after the person enrolled in their plan.  These practices can make getting or keeping coverage unaffordable.

The discussion below focuses on some of the issues faced by people with health issues in the pre-ACA non-group insurance market.  These pre-ACA insurance practices highlight some of the challenges in providing access and stable coverage for people and some of the issues that any ACA replacement plan will need to address. Many ACA replacement proposals have not yet been developed in sufficient detail to fully deal with these questions, or in some cases may defer them to the states.

We start by briefly summarizing key differences between the ACA and pre-ACA insurance market rules for non-group coverage that affect access and continuity of coverage.  We then focus on pre-ACA access and continuity issues for three different groups: (1) people transitioning from employer coverage or Medicaid to the non-group market; (2) people with non-group coverage who develop a health problem; and (3) people who are uninsured (are not considered to have continuous coverage) who want to buy non-group coverage.  After that, we discuss how medical underwriting and rating practices can segment a risk pool, initially and over time, and challenges that this poses for assuring continuous coverage.  We end by reviewing some of the policy choices for addressing the challenges that have been raised.

CMS Checklist For State 1332 Waivers Focuses On High-Risk Pools, Reinsurance

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http://healthaffairs.org/blog/2017/05/12/cms-checklist-for-state-1332-waivers-focuses-on-high-risk-pools-reinsurance/

On May 11, 2017, the Centers for Medicare and Medicaid Services and the Department of the Treasury released a checklist for state 1332 innovation waiver applications. Following up on Health and Human Services Secretary Price’s letter to state governors of March 13, 2017, the checklist specifically focuses on state 1332 proposals to support high-risk pools or reinsurance programs.

Indeed, the checklist begins by stating:

The Department of Health and Human Services and the Department of Treasury (the Departments) are interested in working with states on Section 1332 waivers that would lower premiums for consumers, improve market stability, and increase consumer choice. In particular we welcome the opportunity to work with states to pursue Section 1332 waivers incorporating a high-risk pool/state-operated reinsurance program. State-operated reinsurance programs have a demonstrated ability to help lower premiums, and if the state shows a reduction in federal spending on premium tax credits a state could receive Federal pass-through funding to help fund the state’s reinsurance program.

The checklist restates the procedural requirements that states must meet under the current 1332 rules, such as posting a notice of the waiver proposal and accepting comments for at least 30 days, holding two public hearings, and consulting with Indian tribes where relevant.

Most elements in the checklist, however, describe specifically what information states must submit with applications for a 1332 waiver involving a reinsurance or high-risk pool program. While states must generally document state legislative authority to operate a 1332 waiver program, a state seeking a waiver to operate a high-risk pool or reinsurance program must establish that the legislation makes the program contingent on 1332 waiver approval or that the program will only become operational if the waiver is approved. Otherwise, the state would not be able to establish that federal 1332 waiver pass-through funding was necessary for the program.

A state must specify the provisions of the ACA it proposes to waive, which might, a footnote explains, include the ACA’s single-risk pool requirement for a reinsurance or high-risk pool proposal. State 1332 waiver proposals must include economic and actuarial data and analyses documenting the effect of the proposal on coverage and on comprehensiveness and affordability of coverage. A reinsurance/high-risk pool proposal would have to describe a baseline of premiums and coverage without the waiver and then compare this to projections of coverage and premiums under the waiver.

Proposals for 1332 waivers must explain how they would affect federal budget neutrality. A state seeking a reinsurance or high-risk pool waiver must establish a baseline of federal expenditures without the waiver and then show how federal expenditures or revenues for premium tax credits, shared responsibility payments, exchange user fees, and health insurance provider fees would change if the proposal is implemented.

States must further submit a timeline for implementation. They must describe whether they would use a condition-based list for a reinsurance program or an attachment-point-based model and the incentives they would offer providers, insurers, and enrollees to manage health care costs and utilization. They must describe how the program would affect other provisions of the Affordable Care Act and how it would provide out-of-state coverage for those who need it. States must report the actual second-lowest-cost silver benchmark plan premium annually, as well as an estimate of what it would have been without the program. The checklist further states, “For comprehensiveness, if there is no change to the provision of the ten Essential Health Benefits (EHB) identified in the benchmark plan, the state can indicate that it will report on any modifications from federal or state law on an annual basis.”

In sum, the checklist provides a roadmap for states that want to pursue high-risk pool or reinsurance 1332 waiver proposals, indicating again the priority that the Trump administration places on this approach for increasing the affordability of health insurance coverage.

These 50 Health Issues Count as Pre-Existing Conditions

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http://fortune.com/2017/05/04/ahca-pre-existing-conditions/

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The Republican plan to repeal and replace the the Affordable Care Act (ACA), which narrowly passed a vote in the House today, rolls back protections for people with pre-existing conditions, which could increase health care costs for an estimated 130 million Americans.

The American Health Care Act stipulates that states can allow insurers to charge people with pre-existing conditions more for health insurance (which is banned under the ACA) if the states meet certain conditions, such as setting up high-risk insurance pools. Insurers still cannot deny people coverage outright, as was a common practice before the ACA’s passage, but they can hike up premiums to an unaffordable amount, effectively pricing people out of the market.

In fact, premiums could reach as high as $25,700 per year for people in high-risk pools, according to a report from AARP. People who receive insurance through their employer would not be affected, unless they lost their job or moved to the individual insurance market for some other reason.

But what counts as a pre-existing condition? While it depends on the insurer—they have the right to choose what counts as “pre-existing”—these ailments and conditions were universally used to deny people coverage, according to the Kaiser Family Foundation, a nonprofit focusing on health care research.

  • AIDS/HIV
  • Alcohol or drug abuse with recent treatment
  • Alzheimer’s/dementia
  • Anorexia
  • Arthritis
  • Bulimia
  • Cancer
  • Cerebral palsy
  • Congestive heart failure
  • Coronary artery/heart disease, bypass surgery
  • Crohn’s disease
  • Diabetes
  • Epilepsy
  • Hemophilia
  • Hepatitis
  • Kidney disease, renal failure
  • Lupus
  • Mental disorders (including Anxiety, Bipolar Disorder, Depression, Obsessive Compulsive Disorder, Schizophrenia)
  • Multiple sclerosis
  • Muscular dystrophy
  • Obesity
  • Organ transplant
  • Paraplegia
  • Paralysis
  • Parkinson’s disease
  • Pending surgery or hospitalization
  • Pneumocystic pneumonia
  • Pregnancy or expectant parent (includes men)
  • Sleep apnea
  • Stroke
  • Transsexualism

But Cynthia Cox, Kaiser’s associate director, notes that the above list is a conservative sampling of all of the issues and maladies that insurers could count as pre-existing conditions. ” There are plenty of other conditions, even acne or high blood pressure, that could have gotten people denied from some insurers but accepted and charged a higher premium by other insurers” says Cox.

Here are some examples of those other conditions that experts have noted could hike premiums:

  • Acid Reflux
  • Acne
  • Asthma
  • C-Section
  • Celiac Disease
  • Heart burn
  • High cholesterol
  • Hysterectomy
  • Kidney Stones
  • Knee surgery
  • Lyme Disease
  • Migraines
  • Narcolepsy
  • Pacemaker
  • Postpartum depression
  • Seasonal Affective Disorder
  • Seizures
  • “Sexual deviation or disorder”
  • Ulcers

The left-leaning Center for American Progress notes that high blood pressure, behavioral health disorders, high cholesterol, asthma and chronic lung disease, and osteoarthritis and other joint disorders are the most common types of pre-existing conditions.

Just how expensive are pre-existing conditions? A recent report from the Center for American Progress found that insurers could charge people with metastatic cancer as much as $142,650 more for their coverage, a 3,500% increase.

A Squeaker In The House Becomes Headache For The Senate: 5 Things To Watch

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A Squeaker In The House Becomes Headache For The Senate: 5 Things To Watch

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After weeks of will-they-or-won’t-they tensions, the House managed to pass its GOP replacement for the Affordable Care Act on Thursday by a razor-thin margin. The vote was 217-213.

Democrats who lost the battle are still convinced they may win the political war. As the Republicans reached a majority for the bill, Democrats on the House floor began chanting, “Na, na, na, na … Hey, hey, hey … Goodbye.” They claim Republicans could lose their seats for supporting a bill that could cause so much disruption in voters’ health care.

Now the bill — and the multitude of questions surrounding it — moves across the Capitol to the Senate. And the job doesn’t get any easier. With only a two-vote Republican majority and no likely Democratic support, it would take only three GOP “no” votes to sink the bill.

Democrats have made clear they will unanimously oppose the bill. “Trumpcare” is just a breathtakingly irresponsible piece of legislation that would endanger the health of tens of millions of Americans and break the bank for millions more,” said Senate Minority Leader Chuck Schumer (D-N.Y.).

And Republicans in the Senate have their own internal disagreements, too.

Here are five of the biggest flashpoints that could make trouble for the bill in the upper chamber.

What Are Pre-Existing Conditions and What Would the GOP Bill Do?

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http://www.nbcnews.com/health/health-care/what-are-pre-existing-conditions-what-would-gop-bill-do-n754836

Image: Planned Parenthood Funding Threatened By GOP Legislation

Important background for understanding what happened today in the House:

America has the only healthcare system in the world designed to avoid sick people. Private for-profit health insurers do whatever they can to insure groups of healthy people, because that’s where the profits are. They also make every effort to avoid sick people, because that’s where the costs are.

The Affordable Care Act puts healthy and sick people into the same insurance pool. But under the Republican bill that just passed the House, healthy people will no longer be subsidizing sick people.

Healthy people will be in their own insurance pool. Sick people will be grouped with other sick people in their own high-risk pool – which will result in such high premiums, co-payments, and deductibles that many if not most won’t be able to afford the cost.

Republicans say their bill creates a pool of money that will pay insurance companies to cover the higher costs of insuring sick people. Rubbish. Insurers will take the money and still charge sick people much higher premiums. Or avoid sick people altogether.

The only real alternative here is a single-payer system, such as Medicare for all, which would put all Americans into the same giant insurance pool. Not only would this be fairer, but it would also be far more efficient, because money wouldn’t be spent marketing and advertising to attract healthy people and avoid sick people.