| Today's Managing Health Care Costs Number is 5 |
John McCain rose to the occasion last week and cast one of 51 deciding votes against the ill-named Health Care Freedom Act, aka skinny repeal, which would have led to loss of health coverage for 16 million Americans. The "repeal and replace Obamacare" movement has been declared dead, although yesterday President Trump tweeted continued threats to blow up the exchanges by not continuing Cost Sharing Reduction payments, and even threatened to stop paying the employer portion of health care premiums for Congressmen and their staffers. So the effort to repeal is not dead.
A bipartisan group of 40 moderate Republicans and Democrats in the House has just offered ` to increase stability of the individual markets and lower health care costs. This was first reported on Politico on Sunday. I'm not confident that Paul Ryan would ever bring this bill up for debate - and if he did, it's not clear there are enough votes to pass it. But there are some good ideas here. The five pillars of this legislation
- Fund the Cost Sharing Reductions. They are necessary for exchange policies to be useful for those with low incomes (but over 133% of the federal poverty level), to be sure that their out of pocket costs for care don't make their ACA plans useless. The dollars in the federal budget are small, and it's likely that health plans would raise premiums (which the feds are also on the hook to pay) -so the winners here will be those with over 400% of FPL income who get insurance on the exchange without subsidies. This will be hard for Republicans to swallow - it increases federal expenditures.
- Create a dedicated stability fund for the states. This could be used to create reinsurance so that health plans didn't have to worry so much about enrolling the sickest of the sick - which would be an important complement for "guarantee issue." Like funding CSRs, this would be a big Republican give.
- Exempt employers with 51-499 employees from the employer mandate. No employer has paid employer mandate penalties so far as this mandate has been delayed, and most employers would intend to continue employer coverage regardless. This could lead to some losing insurance, though - so it will be a bitter pill for Democrats committed to universal coverage.
- Repeal of medical device tax. This tax has also been delayed - it would have raised $20 billion over 10 years. It's not critical to the success of the Affordable Care Act or the individual exchanges. Congressmen and women on both sides of the aisle would be fine with this.
- Promote sale of health plans across state lines. This is already live in a number of states, and the health plans have expressed no interest. States with more rigorous regulation of their health care insurance markets will continue to oppose federal preemption of their regulation, and further fragmentation of the health plan markets could lead to higher prices. States will also worry rightly that a state far away won't be as vigorous in insuring health plan financial stability. Democrats won't like this - especially since the regulations will be written by the Trump Administration. But getting CSRs and a reinsurance type fund might be worth the dangers this could cause. Here's an older KFF brief on the subject, and a recent Sarah Kliff review (see item (4))
So - perhaps my estimation of the potential for a bipartisan approach was needlessly pessimistic. The Republicans might not share the Democratic commitment to universal coverage, but they are not willing to wrench coverage away from millions. The Democrats know they are in the minority - and appear willing to accept some painful compromises.
Again - it's not clear that the House will act on this proposal - but it's heartening to see some bipartisan efforts to improve health care take root.
EmoticonEmoticon