By: Gregory Craig and Matthew Fitting
Following a midterm election cycle in which voters consistently listed health care as their top issue priority, members of the 116th Congress have wasted no time in proposing, introducing, and debating several measures that would significantly impact the way Americans receive and pay for health coverage.
Health Care
Legislation in the U.S. House of Representatives
Most recently, Rep. Frank Pallone, Jr. (D-NJ), the Chairman
of the House Energy and Commerce Committee, on March 26, 2019 introduced H.R. 1884 – the “Protecting Pre-Existing
Conditions and Making Health Care More Affordable Act of 2019”. This legislation
would strengthen many of the consumer protections and pre-existing conditions
provisions of the Affordable Care Act (ACA), promote individual health
insurance enrollment on the ACA Marketplace, and roll back regulatory actions
that the administration has implemented since January 2017. Some of the
specific provisions would:
- Expand income-based eligibility for premium tax
credits used to purchase individual health insurance coverage and increase tax
credits for all income brackets, allowing more individuals to purchase
subsidized health insurance coverage;
- Fix the so-called “family
glitch” to make it easier for low- and middle-income individuals to
purchase subsidized family coverage;
- Rescind the administration’s
final rule expanding the availability of Association Health Plans (AHPs) that can
circumvent many of the ACA’s consumer protections, specifically those involving
Essential Health Benefits (read ANA’s comment letter on AHPs here);
- Rescind the administration’s final rule
expanding the availability of short-term, limited duration insurance plans,
which are not required to comply with any of the ACA’s consumer protections
(read ANA’s comment letter on short-term, limited duration insurance here);
- Require the Department of Health and Human
Services to conduct marketing and outreach for open enrollment with $100
million in annual appropriations (read ANA’s plan year 2018 open enrollment
report here);
- Establish a
state-based reinsurance program that would allow states to set up their own
reinsurance programs, or to use the funds to provide premium subsidies or
cost-sharing support, with a federal reinsurance program as a backstop.
ANA has publicly supported many of the provisions in H.R.
1884 and has consistently promoted a bipartisan proposal – similar to the reinsurance
proposal included in H.R. 1884 above – that Sens. Lamar Alexander (R-TN) and
Patty Murray (D-WA) introduced
in the previous Congress that would have established a similar program and
restored cost-sharing payment reductions that help low-income individuals
afford co-insurance and deductible costs (the Administration canceled
these payments in October 2017).
The proposal that has arguably grabbed the most headlines,
however, is “Medicare for All,” a general campaign slogan that was recently introduced
as legislation by Rep. Pramila Jayapal (D-WA) with a Senate bill
soon to follow to be introduced by Sen. Bernie Sanders (I-VT). The bill would
implement an expanded government-run Medicare program and do away with much of
the private insurance system currently in place (well over half of Americans
currently receive health insurance through their employer or in the
Marketplace).
While the legislation is consistent with ANA’s support
for universal access to health coverage, there are several
provisions that could negatively impact the nation’s four million
registered nurses, as well as the patients for whom they provide care. Some of
these include:
- A fee-for-service program that could
significantly reduce payment rates and have a trickle-down effect on Advanced
Practice Registered Nurses (APRNs), who are currently reimbursed at 85% the rate
that Medicare reimburses physicians for the same work;
- A Medicare Trust Fund that could lead to
uncertainty around payments and impact access to care should beneficiary access
to services exceed the fiscal year budget;
- The establishment of regional offices charged
with recommending changes in provider reimbursement and establishing quality
assurance mechanisms for their regions, which could lead to a patchwork of
coverage and tempt providers to practice where reimbursement rates are higher.
Federal Courts Reviewing
ACA Provisions
The Department of Justice on March 25 unexpectedly sent
a letter to the Fifth Circuit Court of Appeals to state that the Administration
fully supports the December 2018 U.S. District Court decision in Texas v. Azar that would invalidate the
entire Affordable Care Act (the U.S. District Court decision was stayed pending
appeal; the Administration had previously only supported striking down parts of
the ACA, including pre-existing conditions provisions). This case will likely
make its way to the U.S. Supreme Court for a final decision, though that decision
would probably not come until 2020 or later. Invalidating the entire ACA with
no plan to replace it would be extremely disruptive to the U.S. health care
system and would result in enormous insurance coverage and financial losses.
On March 27, the Federal District Court for the District of
Columbia threw
out Medicaid work requirements in both Kentucky and Arkansas. This
is the second time that Kentucky’s Medicaid work requirements have been blocked
in federal court. Arkansas’ work requirements were implemented in June 2018 and
have resulted in 18,000 individuals losing coverage. The same federal court on March
28 issued
a ruling that rejects the administration’s final rule that expands
the availability of Association Health Plans. ANA has consistently
opposed expanding the availability of these plans, as they represent
an end-around of the ACA’s essential health benefits requirements for insurance
coverage.
ANA’s Commitment to
Universal Access to Quality Health Care
ANA is committed to a pragmatic approach to ensuring
universal access to quality, affordable, and accessible health care for all
Americans, particularly vulnerable populations and those with pre-existing
conditions. As ANA stated in a recent press release: “Universal access to a
standard package of essential health care services for all citizens and
residents is of paramount importance to the American Nurses Association. Nurses
have a critical voice in this debate, and ANA is committed to advancing policy
initiatives that provide and expand access to affordable coverage and quality
care for all.”
This is the latest chapter in the decades-old health care debate – we expect that many proposals will be offered before the 2020 election. ANA will continue to be involved and actively advocate for nurses and the patients for whom they provided care.
