Senators were mostly in harmony on suggestions for shoring up the health insurance marketplaces through a reinsurance program and keeping cost-sharing reduction payments.
This article first appeared September 06, 2017 on Medpage Today.
WASHINGTON -- Wednesday's Senate hearing on how to stabilize the Affordable Care Act's (ACA) health insurance marketplaces was notable for its almost total agreement on solutions -- and not just among the senators.
Making sure the cost-sharing reduction (CSR) payments are continued "is the most critical issue you can address to assure market stabilization in 2018," Tennessee insurance commissioner Julie McPeak told the Senate Health, Education, Labor, & Pensions (HELP) Committee; she was referring to money the federal government gives insurers to help low-income enrollees with their copayments and deductibles. "Beyond [that], the government should establish a reinsurance mechanism" so insurers won't be on the hook for very high-cost patients.
"You must permanently fund the CSR payments; that's going to help a great deal," said Washington state insurance commissioner Mike Kreidler. As for reinsurance, "it worked well in the state of Washington for the first 3 years that we had a reinsurance program; we'd like to see it go forward."
"CSRs are the right way to go ahead unless we make other dramatic changes in the future," said Oklahoma insurance commissioner John Doak.
Senators in Harmony -- Mostly
For the most part, senators on both sides of the aisle agreed with them. Appropriating the CSR payments through the end of 2018 will help to "limit increases in premiums in 2018... make certain that health insurance is available in every market, and lay the groundwork for future premium decreases," said HELP Committee chairman Lamar Alexander (R-Tenn.). He also urged support for making 1332 waivers -- which states can use to make changes to their marketplace programs -- more flexible, so states can design programs to meet their unique needs.
"We ought to be able to take this small, limited bipartisan step on health insurance, and if we don't, millions of Americans will be hurt," he said.
"Should these out-of-pocket cost reductions be discontinued, independent analysis suggests that premiums could be an average of 20% higher next year for the most popular plans on the exchanges," said HELP Committee ranking member Patty Murray (D-Wash.). "There will be even more uncertainty in the markets -- and patients and families will likely have fewer options when they go to pick their plans. That's unacceptable and it is avoidable."
That is not to say there was no dissent at the hearing. "We're subsidizing an individual market that does not work," said Sen. Rand Paul (R-Ky.). "Can you fix it, and is it morally and ethically right to take money from taxpayers and give it to insurance companies to subsidize people in the individual market?"
Instead of keeping people in that market, "we should try to figure how to get people into the part of the marketplace that's working," such as the market for large-group self-insured plans, which comprise 36% of the overall health insurance market. "It's probably working better than anything else ... It probably has the lowest increase in rates over time, and they have cheaper prices."
Paul gave the example of the nation's 15 million fast-food workers -- low-income people who are struggling to make ends meet. "These are people we should want to help," he said. Let's let them become part of [self-insured] plans; let's have nationwide health associations ... It would cost the taxpayer nothing. Let's let people associate with other people to buy insurance and get the heck out of the individual market."
Simplifying Waivers
The insurance commissioners also had other suggestions for shoring up the marketplaces. For example, Pennsylvania insurance commissioner Teresa Miller commented that under current law, states that apply for a 1332 waiver must make sure it will be budget neutral, and they must also do the same with 1115 waivers, which deal with state Medicaid programs. "Being able to think about waivers together rather than separately and having overall budget neutrality looked at as a pool ... would allow states to be more innovative."
The 1332 waiver process also could be streamlined, said Alaska insurance commissioner Lori Wing-Heier. "The [1332 waiver] process is somewhat onerous in the fact that there's not a defined application to submit, so states applying are hoping they're supplying data requested by CMS [the Centers for Medicare & Medicaid Services]."
"After that is done, the part that is stifling the states is a 6-month waiting period before we receive final approval," she continued. "The first part of application can be done in ... a couple of months, but then we wait for up to 6 months to see if we received final approval to be funded. I will tell you that CMS was very helpful to us, but it's still a rather lengthy process."
The commissioners had mixed opinions on the value of the health insurance "navigators" hired to help consumers sort through their insurance options and choose a plan. "I think the Navigator program needs some oversight," Doak said. "I would ask the full Senate committee to do an audit of Navigator program to find out whether they are they doing the job they're supposed to be doing."
Instead of using Navigators, "I feel [the enrollment process] should be done by licensed [insurance] brokers," Doak said. "I've been in every county in Oklahoma and ...[there is an] insurance agent on every corner."
But Wing-Heier, of Alaska, disagreed. "We rely on Navigators for enrollment for people in rural Alaska," she said.
The 40% cut to Navigator funding proposed by the Trump administration "would be devastating for our population," she said. "There is also a part that's very cultural in Alaska in that we have a variety of languages. Navigators are able to cross that bridge; they provide that service. We don't have that very readily in the insurance community."
Short Timeline for Action
As the hearing drew to a close, Alexander said it had been very helpful. "I heard three things: reinsurance, CSRs, and more flexibility with 1332 [waivers]," he said, adding that once the current issue of shoring up the marketplace is attended to, "we should be doing more on larger question of addressing healthcare costs."
"We should be looking at what we pay to visit the hospital, what we spend on prescription drugs, and how much excessive paperwork increases our costs, and what should be done to encourage wellness. We should be looking at real ways to bring down the cost of healthcare, which is the easiest way to reduce the cost of health insurance."
When the hearing began, Alexander said his plan was to get consensus on a bill by the end of next week, after the committee finishes three more hearings on this topic, so Congress can act on it by the end of the month, when insurers need to make their final decisions for 2018. Because of the short time remaining to craft a solution, "we're moving at such a rapid pace we'll have to make a recommendation to the full Senate and hopefully come up with something [that enough of them] will support," Alexander told reporters after the hearing ended.
A physician who attended the hearing also praised the outcome. "I think it's amazing we finally had a bipartisan discussion about healthcare," said Kevin Burns, MD, a family physician in Tucson, Ariz.
He praised a suggestion made at the hearing that consumers living in hard-to-insure areas be given the option of buying into the federal employees' health benefits plan. "That would be a very [useful] option to provide more access to insurance," he said.