A key Senate committee is one step closer to forging a potentially bipartisan proposal aimed at stabilizing the insurance markets of the Affordable Care Act (ACA) and bringing down premium costs for some consumers — even as others in the Senate are still maneuvering to repeal or replace the law.
The Senate Health, Education, Labor and Pensions (HELP) Committee today held the last of a series of hearings, which Chairman Lamar Alexander said had been an important exercise in bipartisanship and civility at a time when policymaking — especially surrounding the ACA — was generally rife with division.
“For seven years, hardly a civil word was spoken between Republicans and Democrats on the Affordable Care Act,” said Alexander, a Tennessee Republican. But for several weeks, HELP Committee members and other Senators — from both parties — have been meeting to hammer out differences to find a way to keep more insurers from raising ACA premiums substantially in 2018 or withdrawing from the ACA exchanges, he said.
Alexander said he wanted to present a proposal to Senate leadership the week of September 18 and have a vote and passage by the end of September — before the current budget reconciliation package expires. After that, Republicans would most likely need 60 votes, not 50, to repeal the ACA.
In addition, September 27 is the deadline for insurers to commit to participation in the ACA marketplace.
Alexander acknowledged that it might not be completely smooth sailing, despite the amicable talks so far. “To get a result, Republicans will have to agree to something that many don’t want to agree to — additional funding through the Affordable Care Act. And Democrats will have to agree to something that some of them are reluctant to agree to, and that’s more flexibility for states,” said Alexander, adding, “That’s called a compromise.”
Senator Patty Murray, the top Democrat (Washington) on the HELP Committee, said she was not overly concerned. “I feel optimistic that there’s much more we agree on than disagree,” she said.
Three Issues
Three essential issues are likely to be addressed in the HELP Committee proposal: whether federal cost-sharing subsidies for low-income purchasers are continued; how to cover high-cost patients, whether through a risk pool or expanding eligibility for the high-deductible “copper” ACA plans; and how much leeway to give states that seek so-called section 1332 waivers from ACA requirements.
Manny Sethi, MD, an orthopedic trauma surgeon and president of the nonprofit organization Healthy Tennessee, told the panel that states, not the federal government, could best determine what works for its local population.
“Open the door to innovation, and allow states to create their own insurance products,” said Dr Sethi.
But several senators said they were concerned that giving states too much leeway might allow them to throw out coverage guaranteed by the ACA’s essential health benefits, such as mental health and substance use disorder treatment.
Alexander said he had no intention of removing what he called the “patient protection guardrails” that are part of section 1332 of the ACA, including prohibitions against lifetime limits and exclusion of preexisting conditions. He did not directly address the essential health benefits.
Susan L. Turney, MD, MS, CEO of the Marshfield Clinic Health System, Wisconsin, told the HELP Committee that maintaining cost-sharing subsidies was crucial to her organization — which includes a health plan that participates on the ACA exchange. Of the 30,000 ACA health plan enrolees, more than half receive a federal subsidy, said Dr Turney.
Under the ACA, the federal government has reimbursed insurers for the discounts they give enrollees with incomes under 250% of the federal poverty level.
She urged Congress to find a way to continue those subsidies and to also fully fund the ACA program to reinsure health plans’ losses.
Both Dr Turney and Christina Postolowski, Rocky Mountain regional director of the Denver, Colorado–based nonprofit organization Young Invincibles, also called on Congress to require the Department of Health and Human Services (HHS) to reinstate outreach programs designed to increase enrollment in ACA plans. In early September, HHS announced that it would only spend $10 million on outreach for the 2018 enrollment period that begins in November — a massive reduction from the $100 million spent in 2017.
Alexander tried to motivate his Senate colleagues to take quick action by noting that without it more insurers were likely to withdraw from the ACA exchanges. In 2017, 36% of counties had only one insurer offering a plan — up from 3% in 2016, said Alexander. Next year, the Centers for Medicare & Medicaid Services has estimated that half of counties will have one or zero insurers, he said.
That monopoly power drives up premium costs, which may go up 20% in 2018, he said. The lack of certainty over whether the federal government will continue cost-sharing payments is also likely to push up premiums, said Alexander and insurers at the hearing.
The HELP chairman noted finally that even if President Trump wanted to restore or extend the cost-sharing subsidies, he could be blocked in court.
The US District Court in Washington, DC, has ruled that the subsidies are illegal because Congress had not appropriated the money, said Alexander.
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