Five governors — three Democrats and two Republicans — last week gave a Senate committee their prescriptions for quickly stabilizing the insurance marketplaces, or exchanges, created by the forever embattled Affordable Care Act (ACA).
Their long-term recommendations for the nation’s healthcare system — or lack of one — included giving individual states more leeway in calling the shots on reform.
“Let the states experiment as laboratories of democracy,” Utah Governor Gary Herbert, a Republican, told the US Senate Committee on Health, Education, Labor and Pensions (HELP) on September 6.
The governors were unanimous in urging the federal government to commit to reimbursing private insurers for lowering out-of-pocket expenses of individuals insured through exchange plans. President Donald Trump has threatened to cut off the payments, a move that the Congressional Budget Office said would cause insurers to raise their rates by 20% next year. Like others testifying last week, Montana Governor Steve Bullock, a Democrat, said the government needs to ensure funding for so-called cost-sharing reduction (CSR) payments for at least 2 years to send “a message to the market that there’s going to be stability.”
Democrats have accused the Trump administration of trying to sabotage the exchanges by holding back on CSR payments to insurers as well as drastically reducing the budget to advertise the upcoming enrollment period and counsel individuals about their choice of plans.
“It’s time for the federal government to work with us, not against us,” said Colorado Governor John Hickenlooper, a Democrat, at the hearing.
The five governors also recommended that the federal government help states create reinsurance programs that would attract more insurers to the exchanges and curb premium increases. In such a program, if an enrollee’s healthcare costs top a certain threshold, the state is on the hook for the excess amount as opposed to the insurer. This way, insurers won’t have to charge so much in premiums to cover patients with high-cost conditions.
The ACA started out with a federal reinsurance program, but it expired last year. Alaska launched its own reinsurance program this summer, with about $48 million in funding for 2018 from the federal government and roughly $11 million from the state. Alaska took matters into its own hands after the Centers for Medicare and Medicaid Services granted a state innovation waiver under Section 1332 of the ACA.
States are almost salivating for these 1332 waivers, but the governors told lawmakers last week that the application process is too long and complicated. “We put in for a waiver last August [in 2016] and haven’t received an approval or denial yet,” complained Herbert. “We just need to streamline the process.”
“There’s a Sense You Don’t Trust Us”
The Senate HELP Committee, chaired by Senator Lamar Alexander (R-TN), envisions a bipartisan bill in the next few weeks that would save the ACA exchanges from a collapse that has been long prophesied but has yet to occur. Insurers have until September 27 to turn in their signed contracts for participating in the exchanges next year, and Alexander and others want to put out a welcome mat for them.
However, the five governors also gave the HELP Committee their ideas about strengthening the exchanges and US healthcare in general over the long haul. More than anything, they stressed the need to curb rising costs.
Several governors zeroed in on the high cost of prescription medicine. Letting Medicare negotiate prices with pharmaceutical companies is one solution, said Tennessee Governor Bill Haslam, a Republican. Another is a speedier approval process at the US Food and Drug Administration, which would enable pharmaceutical companies to charge less for their products, in theory at least.
Governors also touted transparency as a cost-control tool: Let consumers know ahead of time what various providers charge for this or that service. Senator Michael Bennet (D-CO), a member of the HELP Committee, warmed up to that approach.
“There’s no other market in America where you can’t know what something costs,” said Bennet.
Transparency about healthcare costs and outcomes played into a discussion of payment reform. Like others, Massachusetts Governor Charles Baker, a Republican, said that third-party payers need to shift from the volume ethos of fee-for-service to the value ethos of pay-for-performance.
The governors agreed that expanding the risk pool for the individual insurance market in each state, and adding younger, healthy adults in particular, was a key for affordable premiums. However, the ACA’s individual mandate to obtain coverage isn’t the only way to stock a risk pool, said Baker. He acknowledged that the mandate is working in his state’s healthcare system, considered a prototype for the ACA. However, penalizing individuals for not maintaining continuous insurance coverage is another alternative, as is automatically enrolling people for insurance, and giving them the right to opt out.
“I think you ought to leave it up to the states,” he said.
The freedom of states to solve the problem of the uninsured on their own as opposed to enduring the proverbial one-size-fits-all solutions of the federal government has been a battle line in the ACA’s tumultuous history from the beginning. In the backdrop is the debate about federalism — which responsibilities belong to the states, and which belong to the government in Washington, DC.
“You trust us with education and so many other things,” said Tennessee’s Bill Haslam. “[With healthcare] there’s a sense you don’t trust us to care for the least of these.”
Follow Robert Lowes on Twitter @LowesRobert
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