Recent proposed regulations from HHS rejuvenated the discussion about federal Exchanges. HHS announced a “partnership model,” where states could split certain Exchange duties with the feds. With little detail in the regulations, states spent a few weeks dreaming about only working on parts of the Exchange that appealed to them, and leaving the rest for HHS to deal with. This lack of information about the partnership models made advocates, who are concerned with the seamlessness of enrollment for consumers, rightfully nervous.

Last week, the Center for Consumer Information and Insurance Oversight (CCIIO) unveiled further information on Exchange partnerships through this PowerPoint at a meeting of state officials. And the good news is that CCIIO is providing striking clarity on the Exchange: either a state creates an HHS-compliant Exchange by 2013 or the federal government will run the Exchange.

Under the federally-run Exchange, a state has a few options for partnerships. For each of these, HHS would run the enrollment and eligibility functions for the Exchange, and therefore the coordination with Medicaid.

1. State Consumer Assistance Partnership: A state would maintain control and oversight of the Navigator program and other direct assistance to help people enroll in health insurance, including outreach and education. But HHS would oversee the website and call center for the Exchange.
2. Plan Management Partnership: States will oversee the health insurance plans in an Exchange, including information and monitoring about the health plan options. HHS would coordinate on oversight of health plans and consumer complaints.
3. States could choose both the Consumer Assistance and Plan Management Partnerships.

HHS was clear that, at this point, a state does not have an option to run only a Small Business Health Options (SHOP) Exchange, and have HHS run the individual Exchange, an idea explored by some states. A few things remain unclear about the federal partnership models, including how financing these Exchanges will work. More information from HHS can be found here.

We think these models could work for states, but Community Catalyst is interested to hear what you think: are the new partnership models going to be good for consumers?

– Christine Barber, Senior Policy Analyst

But for millions of Americans who don’t have job-based coverage, it is not so easy to make an informed choice. Because of differences in how coverage works, even different ways deductibles work, it is almost impossible to compare health insurance options across plans. Even worse, rarely do two insurers use the same definition for the same terminology, leaving consumers to make decisions in the dark.

Thanks to the proposed rule issued last week, this “Wild West” of an insurance market is going to change. As we shift toward a system in which everyone has both the right and responsibility to have coverage, consumers need access to unbiased, standardized information about benefits, cost-sharing, and any limits or exclusions in the policies available to them. This new information, delivered in a consumer-friendly format, will be available for individuals and families buying their own coverage, people with job-based coverage, and coverage sold through Exchanges starting in 2014.

Beginning as early as next year, this information will help consumers make “apples-to-apples” comparisons about what is covered, what is not, and out-of-pocket expenses. Plans must disclose, up front, any limits or exclusions to the plan. All insurers will be required to use the same standard set of definitions, and provide new “coverage examples” that will help consumers assess the relative generosity of each plan’s benefits in common medical scenarios, like pregnancy, breast cancer, or diabetes.

However, the proposed rule also raises questions, and it will be important to see them resolved so that these new disclosure rules truly benefit consumers. For example, the final version of the rules should clearly state that insurers and group health plans must make available the summary of coverage on their webpages, healthcare.gov, and on current and future Exchange sites. Consumers should not have to make special requests or provide personal information to get this information. The Massachusetts Exchange makes this kind of comparative information available on its website – and Congress intended all Americans to have access to similar shopping tools.

The proposed rule also requests comments on whether larger employers should be allowed to embed the new coverage summary in their “summary plan description” (SPD), which is a detailed description of the plan’s coverage and how it operates. But those SPDs are often highly technical and complex. Most likely, embedding the short, consumer-friendly summary of benefits form in the lengthy SPD means it will never be seen by the vast majority of employees.

The Administration is asking for comments on these issues before they finalize the rules. Insurance companies and employers are already complaining loudly – it will be important for consumer groups to weigh in too.

– Sabrina Corlette, Research Professor
Health Policy Institute, Georgetown University

Note from Community Catalyst: Contact Christine Barber (cbarber@communitycatalyst.org) if you are interested in commenting to HHS and are looking for assistance.

For those of you keeping score at home, the law has three major components:

• – Vermont Health Benefit Exchange: The Exchange — established as a division within the Vermont Department of Health Access (the state Medicaid agency) — will facilitate purchase of affordable, qualified health plans in the individual and group markets and will meet all other requirements specified in the ACA for state Exchanges. Upon the implementation of Green Mountain Care (the name for the new single-payer system), the Vermont Health Benefit Exchange will cease operation.
• – Green Mountain Care: Upon receipt of the necessary federal waivers and approval of a financing plan by the legislature, Green Mountain Care will be implemented to provide comprehensive, affordable, high-quality, and publicly financed health care coverage for all Vermont residents. Assuming that the necessary waivers are granted, the federal funding previously provided in the form of premium tax credits, cost-sharing subsidies, and small business tax credits under the ACA would be used to partially finance Green Mountain Care. The state will also seek to use Medicare, Medicaid, and CHIP funds as a financing mechanism.
• – Green Mountain Care Board: A board will also be created to oversee the development and implementation of health care payment and delivery system reforms designed to control health care costs and maintain health care quality in Vermont. The board will have five members, nominated by a new Green Mountain Care Nominating Committee and appointed by the governor with the consent of the Senate.

The major policy question left to be resolved by the law is how Green Mountain Care will ultimately be financed. However, the law does set up a timeline for this to be resolved. In January 2013, financing plans for both the Exchange and Green Mountain Care must be submitted to the legislature for consideration. Another important question is whether — and when — Vermont will be able to obtain the various federal waivers it needs (including ACA, Medicaid, and Medicare waivers).

Vermont’s single-payer law demonstrates just how far the ACA’s coverage framework could take us in terms of reforming our health care system. While a single-payer system certainly isn’t required by the ACA, the law is potentially flexible enough to allow this as well as other approaches to increasing access, bending the cost curve, and improving quality of care.

For some additional commentary on the provisions of H.202, check out this post by our partners at the Vermont Campaign for Health Care Security Education Fund over at Say Ahhh and this interview conducted by Ezra Klein. For the latest updates on the single-payer effort in Vermont as implementation moves forward, check out the Vermont Public Interest Research Group’s campaign site.

—Patrick M. Tigue, Children’s Health Care Coordinator
New England Alliance for Children’s Health

If you’re not already planning to tune in to the President’s health care summit tomorrow, maybe it’s time to reconsider. It will be streamed live here, from 10 AM-4 PM Eastern. Forget Lindsey Vonn and The Office baby special: This is must-see TV.

And if you can’t convince your boss that six hours of C-SPAN is equivalent to 30 minutes for lunch, you can follow the Hub’s twitter feed right from your desktop for a live analysis of what’s going down at Blair House (and maybe a little reform haiku thrown in, too.)

Reaching the Summit

With the release of his plan—really a series of amendments to the Senate-passed Patient Protection and Affordable Care Act (PPACA)—President Obama  is ready to embark on the last leg of the health reform journey. Key changes in the proposal include:

•    Improvements in affordability for low- and moderate-income families in the Exchange. Relative to the Senate bill, most families will either pay less and/or get better benefits.

•    Stronger oversight of health insurance premiums. The proposal would give the HHS Secretary the power to deny or modify excessive premium increases as well as strengthen the ability of state insurance regulators to oversee rates.

•    Phasing out of the coverage gap known as the “doughnut hole” in Medicare Part D, making prescription drugs more affordable for seniors.

•    Increased Medicaid funding for all states (and territories), while eliminating the special funding deal for Nebraska.

•    Equalizing the treatment of union and nonunion health benefits with regard to the excise tax on high-cost plans and also adjusting for age, occupation and gender of workers so that firms with an older and sicker workforce would not be hit as hard.

The President also proposed a series of payment integrity and anti-fraud measures to reduce payment errors in Medicare and Medicaid, drawn largely from Republican proposals. (Full summary of the proposal is available here).

Democratic leaders in the House and Senate have reacted positively to the President’s proposal and seem poised to move forward with reform post-summit, with or without a bipartisan agreement that no one is expecting.

Interestingly, not all of the President’s proposals seem to fit neatly into the rules of budget reconciliation. This suggests that some ideas, such as increasing federal authority over insurance rates, will have to get 60 votes in the Senate in order to survive. However, this is likely a win-win for the Democrats: either the rate regulation provision stays in, or Republicans will have to go on record as siding with insurers against consumers on insurance rates.

Summit Watching Guide

The President has continued to sound the theme of bipartisanship by posting on a website all of the Republican-backed ideas already included in PPACA, and offering to post a Republican proposal or statement of principles side-by-side with the President’s plan.    Republican Congressional leaders, however, aren’t having any of it.

The continued trash-talking of the summit obscures the dirty little not-so-secret that the difference between the Republican and Democratic proposals is not about different means to reach the same end, but entirely different ends.

First, Congressional Republicans by and large reject the premise that all Americans should have guaranteed access to secure affordable health insurance and health care. Secondly, they reject the idea that a stronger public-interest watchdog and a new set of rules is needed to correct fundamental weaknesses in the current health insurance market.These are the central premises of the plans put forward by the President and Congressional Democrats and they are beliefs strongly held by the majority of Americans, notwithstanding their skittishness and disillusionment with the process. (Read Real Reform, Community Catalyst’s analysis of the differences between the approaches put forward by the President and the Republicans here.)

At least one prominent Republican, California Governor Arnold Schwarzenegger, has been willing to call out his party on their stance—calling the demand that the summit start with a blank piece of paper “bogus.” (Now that’s a maverick.)

Because the divide between the two parties is so fundamental, at the summit itself we can expect neither a real attempt to reach bipartisan agreement, nor even a real debate over the merits of various policies.

Instead this will be a battle of competing narratives. The President and Congressional Democrats will to try to focus the discussion on the problems with the status quo and substantive ideas for addressing those problems, while the Republican will try to reinforce their anti-government mantra. (If watching 4 to 6 hours of this kind of sparring is not your idea of fun, you can liven it up by taking a drink every time a Republican says “job-killing big government takeover.”)

Look for a special post-summit Insider Friday!

–Michael Miller, director of strategic policy

So this week we begin to share why we’ve been drinking so much office coffee this past year, and spending more time connecting with the Congressional switchboard than with our families.

The first story is from Ann Rudy, a field coordinator here.

My mom, who is 60, works as a hairdresser in Texas. Her employer does not offer insurance to employees so my mom and her husband, who is self-employed, purchased policies on the individual market.  She has worked since she was 16 and has always been healthy.  Like many without an affordable insurance option, she rolled the dice when she purchased a high-deductible plan.  Unfortunately, she lost.

Several months later, my mother fell. By the end of the day, she was in pain and was having trouble moving one of her legs.  She thought she could ‘walk it off,’ but eventually she went to the ER in pain. She had shattered her hip.  After major surgery and a hospital stay, my mom is now chipping away at her $10,000 credit card bill.

National health reform could prevent this from happening to others, or to my mom again. Small businesses like my mom’s salon would get tax credits for offering insurance to their employees. And if they didn’t offer an affordable insurance option, she would be able to shop for a plan in the insurance Exchange, where companies would be required to make clear what a plan covers and how much it costs. (In Texas and other states, no such requirement exists right now.) My mom might have qualified for new subsidies to help with her premium and out-of-pocket costs. And new rules in the federal bills would set limits on out-of-pocket expenses, so someone who falls sick—or a healthy person who takes a fall—would never be asked to pay $10,000 of her medical costs from her paycheck, or on her credit card.

If you have a story to share about how health care reform matters to you, please email us at hub@communitycatalyst.org.

]]> http://blog.communitycatalyst.org/index.php/2010/02/09/the-point/feed/ 0 http://blog.communitycatalyst.org/index.php/2009/11/02/218-that-elusive-magic-number/ http://blog.communitycatalyst.org/index.php/2009/11/02/218-that-elusive-magic-number/#comments Mon, 02 Nov 2009 22:17:22 +0000 admin http://blog.communitycatalyst.org/?p=141 House prepares to bring a strong reform package to the floor
On Thursday, House leadership unveiled a strong health reform package and plans to begin debate on it late this week.  The House bill gelled in the middle of last week when leaders judged that a final push to get 218 votes for a bill that included the “robust public option”—a public insurer that would pay rates based on what Medicare pays—was going to fall short.

Instead, they put out a bill that includes a public insurance plan that would negotiate rates with providers.  The CBO projects this version would save less money, so Leadership made up for the lost savings by proposing a further expansion of Medicaid to 150 percent FPL instead of the 133 percent that cleared committee in the original bills.

Community Catalyst is strongly supportive of the House bill, which goes beyond earlier drafts in a number of respects. It includes a national insurance Exchange that also gives states the option of creating their own Exchanges, new rules that prevent insurers from denying coverage to people with pre-existing conditions or charging people more because they are sick, expands Medicaid, adds a long-term care insurance program for disabled adults, requires health plans to allow young people through age 26 to remain on their parents’ policy, and eliminates the Medicare doughnut hole by 2019, rather than 2024.

Compared to the bill taking shape in the Senate, the House bill is likely to provide better benefits, better subsidies and more progressive financing while reducing the federal deficit and still costing less than the $900 billion ceiling set by President Obama.  Compared to the Senate, the House leadership appears more willing to take on segments of the health care industry and also includes a more significant employer responsibility provision.  (As a result, it faces stiffer opposition from these interest groups, though insurers are opposing the Senate bill as well).  However, according to some analysts, the House legislation does less to reduce spending over the long run than the proposal that passed the Senate Finance Committee.

While the House bill represents a huge step toward quality affordable health care for all, it includes a couple of notable weaknesses. The bill bars most workers who have employer-sponsored insurance from receiving subsidies in the health insurance Exchange.  Instead, workers would be required to take up their employer offer of coverage unless its cost exceeds 12 percent of their income, a requirement that would be too burdensome for low-wage workers.  A better approach would be to exempt workers from the mandate requirement on a sliding scale, as Massachusetts does.

A second problem is that the House legislation assumes that coverage is “always affordable” for people whose income exceeds 400 percent of the federal poverty line.  This provision would be burdensome, especially for older adults with income just above the cut-off point for subsidies.  Although the bill limits premium variation based on age, an older person could still pay twice as much as young adult, leaving them with a very substantial premium liability. Establishing a ceiling on how much people could be required to pay for coverage, regardless of income, would remedy this problem.

The House bill also eliminates the Children’s Health Insurance Program, known as CHIP, and assumes that children who are not Medicaid eligible will get their coverage through employer plans or through the Exchange.

There a number of potential benefits to moving children off of CHIP, not least of which is moving away from a block grant program that gives states the ability to offer relatively limited coverage (flexibility that states have not generally utilized to date) and instead give children a federal guarantee of coverage.

But while under law, CHIP plans may be limited, in practice most states have provided kids with comprehensive coverage.  As a result, children transferring from CHIP to Exchange coverage could see their benefits reduced and their costs increase.   Preserving CHIIP as a program that provided additional benefits and cost-sharing protections for children in families above the income eligibility threshold for Medicaid could help ensure that children get the health care they need.

For more details on the House bill see this updated Community Catalyst summary and discussion.

218, that elusive magic number
As the House prepares for floor action as soon as this week, several hurdles to passage still stand.  Here are the three main sticking points:.

•    Abortion
A number of House Democrats, led by Michigan Representative Bart Stupak, want to have a vote on language that would preclude plans that receive federal subsidies from including abortion coverage.  The current language in the House bill separates out the cost of abortion coverage from a benefits package, and requires the value of subsidies to be calculated without it. But Stupak wants a stricter prohibition on abortion coverage and claims to have the support of 40 House Democrats, which could be enough to block reform if they do not get their requested vote.

•    Immigrant Coverage
A debate is simmering within the House about whether to adopt a provision, favored by President Obama, that would prohibit undocumented immigrants from buying insurance coverage through the Exchange, even with their own money.  Many progressives, especially members of the Congressional Hispanic Caucus, are concerned about the lack of equal treatment for legal immigrants.  Advocates and lawmakers are now contemplating whether to push for an amendment that would give states the option to receive federal matching funds to cover certain legal immigrants through Medicaid.

•    Public Option
While the House leadership believes they lack the votes for a public option tied to Medicare rates, some progressives still want a chance to vote on that amendment and may block action if they don’t get it.

All of these issues could be addressed in a “manager’s amendment” or in the rule that will govern debate in the House later this week.

Affordability woes in the Senate
In case you missed it in our Friday blog post, the Senate is still struggling with the affordability issue.

While sources on the Hill confirm that the Senate is trying to make badly-needed affordability improvements for moderate-income households, they are trying to do it while still reducing fees paid by medical device manufacturers and an excise tax on high-cost insurance plans.  As a result, the best idea the Senate appears able to come up with at this point is to reduce premiums for moderate-income households by raising them for those at the bottom (We compared this proposal with the SFC bill and House leadership plan here.)

Timetable Update
House: The House plans to start floor debate late this week and to finish no later than Thanksgiving.

Senate: A backlog of work at CBO has slowed progress on the Senate side.  Given the slower pace of debate in the Senate, and with Veteran’s Day and Thanksgiving on the holiday horizon, the Senate is unlikely finish debate this month, though there is still a good chance they will finish before Christmas.  That means though, that resolving the differences between the House and the Senate will likely extend into next year.

Shameless plug department

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–Michael Miller, Director of Strategic Policy