Category: ACA

Trump Administration’s Moves Continue to Fracture the U.S. Healthcare System

  

The Trump Administration continues to create uncertainty in the U.S. healthcare system – uncertainty that has led states to take measures which could ultimately result in drastically disparate health outcomes, both across states and populations. In addition to repealing the individual mandate in December 2017’s tax legislation, the administration in the last several months has proposed several rules which could further exacerbate these divides (ANA will submit comment letters on all three of these proposed rules).

  • The first of these rules was issued by the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA) and would act to expand the ability of employers to offer health insurance coverage through Association Health Plans; ANA submitted a comment letter on this proposed rule on Friday March 2nd. This rule would facilitate the proliferation of insurance coverage that does not cover Essential Health Benefits, and would make it more difficult for older individuals and those with pre-existing conditions to purchase individual health insurance coverage while driving up prices in the federal and state health insurance exchanges.
  • The second proposed rule comes from the U.S. Department of Health and Human Services (HHS) Office for Civil Rights and focuses on enforcing statutory conscience rights of healthcare workers – including nurses. ANA strongly supports the fundamental right of nurses and all healthcare workers to listen to their moral and ethical consciences; however, we also believe that this proposed rule as written opens the door for discrimination against marginalized groups, including LGBT individuals, which already experience lower quality health outcomes and would lead to further population health disparities.
  • The third proposed rule comes from the U.S Department of Treasury’s Internal Revenue Service, EBSA, and HHS and focuses on expanding the use of short-term, limited-duration insurance. This rule would have an impact similar to that of the Associated Health Plan proposed rule described above.

These rules – in addition to the repeal of the individual mandate – threaten to fracture the national healthcare system framework established under the Affordable Care Act (ACA). This is not the first time this has happened since President Obama signed the ACA into law in 2010 – the King v. Burwell  Supreme Court decision in 2012 ensured that not all states would provide the same level of Medicaid coverage, and as a result 17 states still have yet to expand Medicaid. The Trump Administration, however, has accelerated this fracturing, and states are increasingly taking measures to react to these federal policy decisions.

Some states – including California, New York, and Maryland – have seen proposals to pass their own state-level individual mandate, while others such as Oregon have created reinsurance programs to insulate insurance companies from the extremely high costs of covering patients with chronic and complex health conditions – thus helping to keep premium costs down for the overall population.

Other states – bolstered by the Trump Administration’s moves – have pushed the limits of what is allowable under the ACA. While the ACA allows states to experiment with their health systems under Section 1332 waivers, some states are arguably moving beyond what is allowed even under such waivers. Idaho, for instance, recently attempted to allow insurers to sell individual health insurance policies which do not comply with some of the ACA’s requirements, including the elimination of lifetime caps and the coverage of Essential Health Benefits. The Trump Administration, however, informed Idaho that this plan is non-compliant with federal statute and that the sale of such plans would not be allowed.

ANA strongly supports innovation and creative approaches to ensuring comprehensive, affordable healthcare coverage for all Americans. These proposals, however, would likely have the opposite effect by driving up premium prices, pushing individuals in at-risk populations out of the insurance market, and widening population health disparities. ANA reiterates its previously stated support for legislative proposals which shore up the individual health insurance marketplace and reinstate critical cost-sharing reduction payments to help low-income families pay for much-needed primary care and other healthcare services.

Photo: Evan Vucci/Associated Press

A Budget to Nowhere

  

 

The good news is that the budget unveiled Monday by the Trump administration is dead on arrival. The two-year agreement reached by Congress last week makes this budget even less relevant than most presidential budgets, and more importantly the congressional spending deal funds a number of crucial health programs that were in danger of losing funds. The bad news is that the President’s budget seeks to normalize policy proposals that would either cripple or eliminate altogether a number of crucial federal programs that provide critical aid for nurses and their patients.

Nursing Workforce Development Programs covered under Title VIII of the Public Health Service Act would be particularly hard hit, with cuts of almost 65% at a time when nurses nationwide desperately need this funding to continue providing quality care. The budget slashes $145 billion overall, eliminating all but one program under Title VIII (the NURSE Corps Loan Repayment and Scholarship Program, which would be funded at $83 million). As a result of this drastic and misguided approach, the Nursing Community Coalition (of which ANA is a member) announced their strong opposition earlier today.

Even when the President’s budget takes one step forward by allocating new funds, it simultaneously takes two steps back, as with funding to combat the opioid crisis. While the budget proposal would allocate $13 billion, experts estimate that at least $32 billion is needed to address this lethal epidemic. This new funding would also come at the expense of the Centers for Disease Control and Prevention (CDC), which would lose $1 billion and suffer particularly deep cuts to programs aimed at reducing chronic disease, bolstering public health preparedness, and overseeing occupational safety and health.

Perhaps most alarmingly, the budget embraces the approach of the already-rejected Graham-Cassidy legislation to repeal and replace the Affordable Care Act. This approach would implement massive cuts to Medicaid and eliminate its state-based expansion (which 33 states to date have chosen to embrace). It would also end the subsidies that help a vast majority of Americans who obtained health coverage under the ACA-implemented marketplace pay for their premiums.

Rather than promoting a misguided and out-of-touch budget, ANA urges the administration to instead focus on more pressing priorities, including helping Congress reach an agreement on those affected by the Deferred Action for Childhood Arrivals (DACA) program, as well as efforts to stabilize the health insurance marketplace following the repeal of the individual mandate late last year. Too many of the ideas included in this budget have been rejected by bipartisan congressional majorities. Like those ideas, this budget should similarly be put aside.

Trump Administration Continues to Undermine Healthcare for Low-Income Americans

  

The Trump Administration has picked up in 2018 where it left off in 2017 by dealing two more blows to the American health care system. The Department of Labor (DOL) on January 5th published a proposed rule which would expand the ability of groups of employers to create Association Health Plans (AHPs), while today the Centers for Medicare & Medicaid Services (CMS) sent a letter to state Medicaid directors indicating support for states to implement work requirements for “able-bodied” adult Medicaid beneficiaries. These moves threaten to restrict access to critical and comprehensive healthcare services for low-income Americans, even as the healthcare coverage of 9 million American children hangs in the balance as Congress continues to drag its feet on a long-term re-authorization of the Children’s Health Insurance Program (visit ANA’s CHIP action page here).

Association Health Plans

As I wrote in a blog post in October, AHPs currently exist and are used primarily by small businesses to purchase group health coverage, but are regulated under the provisions of the Affordable Care Act (ACA) in the same way as coverage purchased on the individual health insurance market. DOL’s proposed rule seeks to make it easier for employers to create AHPs by:  1) allowing AHPs to exist for the sole purpose of offering healthcare coverage and 2) broadening the definition of “commonality of interest” to allow for larger AHPs. This would in effect treat AHPs as large group health insurance plans and allow coverage under AHPs to be sold across state lines under certain circumstances.

Expanding the use of AHPs in this way exempts them from important provisions covered under the ACA. As a reminder, the ACA includes provisions on insurance plans sold on the individual market which:

  • Require plans to cover 10 Essential Health Benefits including reproductive and maternal health services and preventive services;
  • Forbid insurers from charging more to individuals due to pre-existing conditions;
  • Limit the amount insurance companies can charge to older individuals based on age.

While DOL notes that a non-discrimination provision within the proposed rule would prevent denying coverage on the basis of pre-existing conditions, AHPs could still select for younger, healthier individuals in other ways and could still charge higher premiums for older individuals, potentially leaving these individuals (who are statistically likely to be sicker) without a coverage option.

Furthermore, these insurance plans are ripe for instances of fraud, abuse, and insolvency. The Government Accountability Office (GAO) in 1992 issued a report which slammed similar small business insurance arrangements and noted that they left hundreds of thousands of enrollees with millions of dollars in unpaid claims, while widely failing to meet state insurance laws and regulations. The GAO report found that some plans tried to duck state insurance regulations entirely. This type of Wild West approach to insurance coverage does not offer the comprehensive level of coverage at a low price that the Trump administration claims. Based on the provisions of this proposed rule, we also expect several lawsuits to challenge this based on the legality under current federal law and on the insurance across state lines aspect.

Work Requirements for Able-Bodied Adult Medicaid Beneficiaries

CMS sent a letter on January 11th to state Medicaid directors announcing its support for states to implement waivers introducing work requirements for non-elderly, non-pregnant adult beneficiaries who are eligible for Medicaid on a basis other than disability. CMS bases its support for work requirements on what it describes as the health benefits of community engagement, including work and work promotion.

This latest attempt by the Trump Administration to restrict Medicaid eligibility is, however, nothing more than a straw man argument. Medicaid expansion ipso facto provides healthcare coverage to working, low-income Americans. According to a December 2017 Kaiser Family Foundation issue brief, roughly 6 in 10 of the 22 million non-disabled adults receiving Medicaid benefits are employed either full- or part-time, while 8 in10 of these adults live in a working family. Most of these individuals work either for small firms or in low-paying industries which do not offer healthcare coverage and thus rely on Medicaid for such.

Further, among those adults who are not working, most report a major barrier to employment such as illness, disability, or care-giving duties. According to the same Kaiser issue brief, Medicaid expansion has not negatively impacted labor market participation; in fact, some research demonstrates that Medicaid coverage supports work.

As such, Medicaid work requirements would likely have little to no positive impact on employment and could even negatively impact both access to healthcare and employment prospects for these Medicaid beneficiaries. From an empirical standpoint, the basis for imposing work requirements on Medicaid beneficiaries seems to stem less from a desire to assist low-income Americans to access critical healthcare services while simultaneously supporting employment, but rather from a preconceived notion as to the characteristics of the individuals who benefit from Medicaid.

The American Nurses Association opposes any action – legislative or executive – which threatens the ability of Americans to access and receive high quality healthcare. This is particularly true when it comes to the most vulnerable Americans. If 2017 showed us anything, it is that this administration is more concerned with scoring political points and reversing gains made in healthcare than it is about actually ensuring high quality healthcare coverage for all Americans; this seems to be the modus operandi in 2018 as well.

We urge the Administration and Congress to work toward finalizing a long-term Children’s Health Insurance Program (CHIP) re-authorization, toward a market stabilization package including cost-sharing reduction payment funding, and toward strengthening the existing healthcare system – which has resulted in coverage for tens of millions more Americans since 2014 – and put an end to these attempts to sabotage Americans’ healthcare for political gain. ANA is committed to working with Congress and the Administration on legislation and regulations which align with our four core principles of health system transformation. These moves, however, represent a major step backward from achieving those principles.