Trump Administration Again Takes Aim at Pre-Existing Conditions

  

Even as individual states take steps to expand health coverage, the Trump administration continues its misguided approach to restricting access to care. The U.S. Department of Justice (DOJ) on Thursday June 7th filed a brief in U.S. District Court in the case of Texas v. United States which indicates that the government will no longer defend the constitutionality of the Affordable Care Act’s (ACA) guaranteed issue and community rating provisions, which protect the ability of the estimated 52 million Americans with pre-existing conditions, such as diabetes and arthritis, to purchase health insurance coverage. These provisions require private health insurance providers to offer coverage to Americans with pre-existing conditions and prohibit them from charging higher premiums based on an individual’s pre-existing condition(s). They are also some of the most popular provisions of the health law, with 75 percent of Democrats and 63 percent of Republicans in support.

These crucial provisions have made it possible for some Americans with pre-existing conditions to purchase health insurance coverage for the first time and have contributed to the decline in the percentage of Americans who are uninsured. In the unlikely event that these provisions are ruled unconstitutional, insurers will once again be able to charge prohibitively expensive premiums to these individuals – or to simply deny them coverage outright. This move by the DOJ also injects a fresh dose of uncertainty into the individual health insurance market, further contributing to instability that the administration and its allies in Congress have created.

Even as the Trump administration attempts this major blow to the health law’s provisions on individuals with pre-existing conditions, it also continues its “death by a thousand cuts” approach to upending the nation’s health system under the ACA. The Centers for Medicare & Medicaid Services (CMS) has indicated to states that it supports state waivers to impose work requirements on “able-bodied” adult Medicaid beneficiaries (the Obama administration denied several similar state waiver requests).

To date, CMS has approved such waivers for Arkansas, Indiana, Kentucky, and New Hampshire, with seven other states waiting for approval. Such requirements require beneficiaries to certify that they have completed a certain number of hours of work or “community engagement” in order to be eligible for Medicaid; if they do not do so, they would lose their Medicaid benefits. Such waivers could potentially act as a barrier to coverage, especially considering that most Medicaid beneficiaries already are employed, while those who are not employed generally face significant barriers to employment.

These moves come even as more states realize the positive impacts of Medicaid expansion and as support for the ACA remains high. On Thursday June 7th – the same day, ironically, that DOJ filed its brief – Virginia Governor Ralph Northam signed into law a bill to implement Medicaid expansion, becoming the thirty-third state (plus the District of Columbia) to do so. This expansion, which will not be implemented until January 1st, 2019, provides Medicaid coverage to an estimated 400,000 additional low-income Virginians. Maine voters also voted overwhelmingly last year in favor of Medicaid expansion in the first ballot initiative to do so; Idaho, Nebraska, and Utah are also considering expansion through similar ballot initiatives.

ANA strongly opposes any attempt to weaken protections for Americans with pre-existing conditions to purchase health insurance coverage in order to receive critical healthcare services (the official ANA statement on this move can be found here), as well as any other attempts to erode the healthcare coverage for any segment of the population. These recent moves unequivocally demonstrate how out of step the Trump administration is with the American people when it comes to healthcare. Even as it attempts to take a wrecking ball to the gains made under the ACA, states are taking steps – with significant popular support – to shore up their own healthcare systems.

Healthcare stands to be a major issue in the 2018 midterm elections – 22 percent of respondents to a recent NBC News/Wall Street Journal poll named healthcare as the most important factor in deciding their vote. The administration’s recent moves demonstrate just how much is at stake in these elections. ANA urges you to support candidates who uphold our core values and principles for health system transformation, as well as to engage with ANA’s Year of Advocacy and Hill Day 2018 activities (Hill Day 2018 will be held on Thursday June 21st). It is vital that nurses’ voices as the nation’s most honest and ethical profession and largest group of healthcare providers are heard in the public sphere and that nurses make their influence known.

Trump Administration Continues Work to Undermine Americans’ Health Care

  

While Congress has thus far in 2018 declined to take up legislation that would dismantle affordable access to health care that was a hallmark of their 2017 agenda, the Trump administration continues to move forward with a number of regulatory initiatives that will continue to advance this misguided approach and cost more Americans the coverage they need.

One plan the administration is currently discussing would allow for wider availability of short-term, limited-duration insurance plans that cover patients for less than a year; another would permit the self-employed and small business employees to make use of association health plans. In both cases, coverage offered would not be required to meet the list of essential health benefits that the Affordable Care Act (ACA) currently requires.

As a result, a vast majority (more than 95%) of healthcare groups that submitted comments on President Trump’s recent plan to scale back these protections said that such an approach was a mistake.

Meanwhile, many of those same groups have come out in opposition of a proposal that would weaken Medicaid by creating work requirements for certain adult recipients who have benefited from Medicaid expansion. While specific efforts to implement such requirements are being led by state governments, it was the administration’s decision to allow such proposals in the first place that has enabled them to do so.

The administration’s argument, however, is disingenuous at best, as that Medicaid expansion 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 in 10 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 health care.

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.

Finally, last year’s tax bill, which included a repeal of the ACA’s individual mandate, continues to wreak havoc on insurance premiums. The Congressional Budget Office (CBO) recently revised its estimates and determined that this repeal will lead to a premium increase of at least 10% in 2019. Premium increases are expected to be finalized state-by-state in early October, roughly a month prior to November’s general elections.

The ACA: Eight Years of Increasing Access to Care

  

The landmark Affordable Care Act (ACA) recently celebrated the 8th anniversary of its enactment. Despite having extended health insurance coverage to millions of Americans and being more popular than ever (the ACA currently enjoys a favorable 54% approval rating), the Trump Administration and Congressional Republicans have repeatedly attempted to undermine and outright repeal the ACA.

The Trump Administration has additionally given states new latitude to impose work requirements, premiums and copayments on non-disabled, adult Medicaid beneficiaries. Such requirements could have a significant negative impact on enrollees; studies have shown that Medicaid coverage actually encourages work, helps individuals avoid crushing medical debt, and has kept millions of Americans out of poverty. Tightening eligibility criteria for adult Medicaid recipients also jeopardizes Medicaid coverage for their children.

In December 2017, Congress eliminated the individual mandate for Americans to purchase health insurance coverage; the Congressional Budget Office estimates that as a result, individual private market premiums will increase by 10% and 13 million Americans will lose coverage. The Trump administration has also proposed rules that would allow for the sale of plans that fail to meet essential health benefits which provide protections for individuals with preexisting conditions. As a result, healthier individuals will be attracted to sparse, less expensive plans, leaving those with more complex health conditions to purchase insurance on the Marketplace. The reliance of sicker individuals on Marketplace plans will further fuel a rise in premiums.

Despite these attempts to undermine critical aspects of the ACA, essential elements of the legislation remain intact, allowing millions more Americans to access critical preventive benefits and other healthcare services. Federal assistance toward the purchase of a Marketplace plan for those with incomes between 100% and 400% Federal Poverty Level (FPL) and federal funding for Medicaid expansion continue to increase enrollment, and essential health benefits requirements ensure that Americans receive all of their necessary care.

The continued popularity and resilience of the ACA illustrate the commitment of the American people to continue to advocate for common sense health care reform that increases the number of Americans enrolled in comprehensive health plans, and their continued resolve to reject proposals that jeopardize access to care for the most vulnerable Americans. ANA continues to oppose attempts to undermine the ACA and remains committed to supporting policies that reduce costs, provide comprehensive coverage and encourage enrollment.