Wednesday, August 23, 2017

Iowa’s Push to Reshape Health Law

Iowa asked for Federal Permission to alter Major Provisions of the Affordable Care Act (ACA) next year, a Proposal that will be closely watched by Officials in other States who hope to Rewrite Parts of the Health Law as Republican efforts to do so in Congress have Stalled.

Iowa’s Plan, which State Officials said they are already preparing to Implement pending Federal Approval, would go further than Proposals that other States have made so far to Revamp the ACA Rules. The Iowa setup would offer just One type of Insurance Plan in the Individual market and Reshape the Subsidies that help people Buy coverage, among other Changes. State Officials, who are formally filing for Federal approval under a Special Waiver setup allowed by the ACA, argue they need to Repair an Exchange Market that is expected to be down to just One Insurer that has requested Sharp Rate Increases for 2018.

States including Idaho, Minnesota, and Oregon have submitted Applications for less-sweeping Waivers that aim to blunt Insurers’ Expense for Covering the Claims of People with Costly Health Conditions. In total, 13 States have passed Laws authorizing State Officials to craft ACA Waiver requests, according to the National Conference of State Legislatures. At least Six others are considering such Legislation.

“The most urgent thing for states is to stabilize the markets,” said Rosemarie Day, a Health Strategist and former Chief Operating Officer of the Massachusetts Exchange. But the Waiver process also “opens the door to trying to accomplish some things Republicans are trying to do,” like Limiting Benefits currently Required under the ACA. “This could be a backdoor way.”

Some States, such as Oklahoma, have Signaled they intend to seek Waivers that, like Iowa’s, could make big Changes to the ACA. If those Proposals proceed and are Granted by the Trump Administration, the upshot could eventually be a Patchwork of Different Insurance Setups across the Country. However, the ACA includes Firm Conditions that such Waivers must meet, including that Coverage must be as affordable and Comprehensive as it is under the Federal Law’s setup.

Iowa Insurance Commissioner Doug Ommen, a Republican, said the State has worked with the Federal Centers for Medicare and Medicaid Services and that it hoped to get its New System up and running before individual-Plan Enrollment kicks off in November. “We’re doing everything that’s needed to start it up as though we already had a yes,” he said. Iowa is also asking Federal Officials to move faster than the 180-day Waiver Review timeline designated by the ACA.

Iowa’s largest Insurer, Wellmark Blue Cross and Blue Shield, said it would Reverse its Plans to exit from the State’s Individual Market and would instead sell Plans in every County next Year if the State won Approval for its Proposal.

CMS Officials have told some States that Waivers could be Approved quickly and seem Open to some of the proposed Changes, People close to the discussions said. A Spokeswoman for the Agency pointed to a March Letter that Health and Human Services Secretary Tom Price sent States encouraging them to look at the process. The Trump Administration has already approved a Waiver for Alaska, which created a Reinsurance program to limit Insurers’ Claims Costs.

In Washington, the approaching Deadline for Insurers on whether to take part in Health Exchanges has put pressure on GOP Leaders to decide whether to take steps to shore up Marketplaces in certain States or to continue wholesale efforts to Repeal the 2010 Law.

The Iowa Proposal would change important Features of the ACA. The Premium Subsidies that enable Lower-Income People to buy Health Insurance would become Flat Payments tied to Age and Income; under the ACA, the Subsidies are tied to Actual Premium Costs in a Region and Cap what Low-Income People must Pay toward those Monthly Bills. Iowa’s setup would also Eliminate so-called Cost-Sharing Subsidies that help Cover Deductibles and other Out-of-Pocket Costs for the Lowest-Income Enrollees.

Consumers would still be able to buy 2018 Plans during this Fall’s Open-Enrollment period. But to Purchase them after Jan. 1st, they would in many cases need to show they had maintained Continuous Coverage, with no Gap longer than 60 days in the previous 12 months. A Reinsurance program would Limit Health Insurers’ Costs for the most-Expensive Enrollees.

Patient groups including the National Alliance on Mental Illness raised concerns about the potentially Higher Health-Care Costs for Low-Income Enrollees under the Iowa plan, largely because of the Elimination of the Cost-Sharing aid. That could leave such Enrollees exposed to Thousands of Dollars in Deductibles and other Out-of-Pocket Charges when they need Care.

The American Cancer Society Cancer Action Network Affiliate in Iowa urged the State this month to Submit a far more Limited Waiver Application, focused on Reinsurance. It warned that the broader Plan “would likely result in decreased access to care for many Iowans” and likely wouldn’t meet ACA Requirements that Waivers provide Coverage as affordable as the Current Law “absent additional policies to ensure that low-income individuals will have access to affordable care options.”

Ommen said the state’s Plan would Reduce the Cost of Premiums for many Enrollees, strengthening the Market by retaining a Healthier Pool of Consumers. The most recent Proposal bolstered the Premium Subsidies for Lower-Income People compared with an earlier draft, he said. “No doubt, we’re balancing a lot of interests here, but we believe we’ve addressed the issue.” He also said the State believed its Application met the ACA’s Waiver Guidelines.

Under the Iowa Plan, “some people would be better off, but others would be worse off,” said Larry Levitt, a Senior Vice President at the Kaiser Family Foundation. Specifically, he said, Lower-Income People might be Losers, largely because of the Lost Cost-Sharing Protections, while Iowa’s Plan would likely help some Middle-Income People who would get a Premium Subsidy under the Iowa Plan but don’t with the ACA.

Other States say they are considering similarly Broad Waiver requests for the future. Ohio is eyeing a Proposal that would pare back a Central ACA Requirement that most People Purchase Health Insurance or Pay a penalty. Oklahoma, which has submitted a Limited Request to set up a Reinsurance Program, is crafting a Broader Proposal that would, among other Changes, Reduce the Number of Health Benefits that Insurance Plans must Cover.

Julie Cox-Kain, the State’s Deputy Secretary of Health and Human Services, said Officials hope to use the Waiver process to Overturn the ACA in the State. “For us, it’s our replace program, and we consider it to be a fairly significant reform,” she said.

If many States complete the Waiver and create State Health Systems, will individual State Single Payer Health Care the next step?

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