Individual Health Insurance Reform Intense Debate

When House Republicans voted Friday to block funding for health care reform implementation (see below), it was with the knowledge that most Americans disapprove of the tactic. A new CBS News poll shows 55 percent of Americans disapprove of the defunding effort while just 35 percent support it. The poll also shows, however, that the Patient Protection and Affordable Care Act (PPACA) continues to be unpopular overall. Just 21 percent think the law will make the health care system better while 23 percent believe it will make things worse. Perhaps most interesting of all is that 44 percent are unsure of what the law does, and they don’t know enough to say what the impact will be. The results seem to suggest the law has gained no traction with the populace in the past year but that voters have a keen sense of fair play in how the issue is addressed.

To keep the government operating for fiscal year 2011 (September 2010 through September 2011), Congress has been passing a series of continuing resolutions (CR) that continue the funding for a set period of time. The current CR runs out the first week in March, so the House last week passed yet another CR, shipped it off to the Senate and headed out of town for a President’s Day recess. Included in the just-passed CR are provisions that would de-fund parts of the 2010 individual health insurance reform law, such as prohibiting the use of federal funds to pay government employees to work on or to implement the PPACA.  The Senate will surely reject this CR because of both the de-funding provisions and the $61 billion in spending cuts for the current fiscal year. Congress will once again confront a looming funding deadline when it returns from recess in a week.

While there is increasing health-related “action” in Congress, such as the de-funding effort and the soon-to-be successful effort to repeal the 1099 requirement, the implementation process within the agencies continues unabated. This is where the real action is, with post-regulation guidance likely to be issued on several fronts in the very near future. Sub-regulatory guidance is expected to touch on the following areas or answer certain questions: 1) Whether group plans, as of 2012, will be allowed to offer a Medicare Advantage-only plan alongside a stand-alone PDP;  2) whether and how insurers have to report PBM administrative costs for medical loss ratio (MLR) purposes;  3) FAQs on the parameters (e.g., national vs. state-by-state reporting) of an insurer’s MLR requirement for ex-pat business;  4) revised rules on already-issued claims and appeals rules; and  5) clarification of the length and breadth of the types of “new business’ that can be sold under a limited benefits plan or mini-med waiver. All of these items will have a bearing on operations at Aetna health insurance and Golden Rule insurance.

The Obama administration has awarded $241 million in grants to seven states to develop a health insurance exchange. Developing the technology to make such a virtual marketplace work is expected to be costly, however. Administration officials hope the grants awarded last week will allow a few states to build systems as “early innovators” that others will be able to adopt. The states receiving grants, which were appropriated by the law last year, are: Kansas ($31.5 million), Maryland ($6.2 million), Massachusetts ($35.6 million), New York ($27.4 million), Oklahoma ($54.6 million), Oregon ($48.1 million) and Wisconsin ($37.8 million). A sign of the sometimes odd nature of health care politics, Kansas, Oklahoma and Wisconsin have Republican governors who have complained bitterly about the new law and are challenging its constitutionality in federal court.

Arizona health insurance Governor Jan Brewer was advised by HHS Secretary Kathleen Sebelius that the maintenance of effort provision of the PPACA does not preclude the state from removing childless adults from the Arizona Health Care Cost Containment System (Medicaid) because the expansion was part of a demonstration project. The Governor and many legislators support this reduction as a means to help address the state’s significant budget deficit. While many view the development as a positive, a legal challenge at the state level is possible because the coverage expansion resulted from a ballot initiative. Also, the health insurance exchange bill was voted out of the House Banking and Insurance Committee by a 4-2-1 margin. Discussion was robust, with Republican members questioning the need to take any action in light of pending litigation against the PPACA. The view that the bill should continue to move to the floor for a full vote prevailed.

The Connecticut health insurance Committee held a hearing last week on a bill that would require public hearings on rate increases. The bill would compel hearings in some cases, and would give the state attorney general and health care advocate the right to argue on behalf of consumers at the hearings and call witnesses. In addition, the bill would change existing law, which states that rates can’t be “excessive”, by defining excessive as “unreasonably high.” Industry representatives said the legislation would conflict with federal reform laws, add administrative burden on the Insurance Department and, ultimately, increase costs. Keith Stover, lobbyist for the Connecticut Association of Health Plans, testified that rates already have to be actuarially sound and that medical insurance costs are, in fact, increasing. The Insurance Department said lawmakers should hold off on changes until incoming Commissioner Thomas Leonardi reviews the plan.

The Public Health and Insurance committees held a joint hearing on the SustiNet public option bill, the insurance exchange bill, the “pooling” of all public employees bill (to be known as the Connecticut Health Partnership) and a bill to allow the state to pool state employee and Medicaid pharmaceutical purchasing. The most important development of the day was the Malloy Administration’s written testimony. The state’s Budget Director Ben Barnes was not only tepid toward SustiNet as a whole, he was quite clear that the SustiNet bill gives too much budgetary power to a quasi-public agency (almost $8 billion in state health spending) and raises questions about SustiNet’s cost and savings projections. He pointed out that certain Medicaid concepts in the bill are against federal law, including allowing the agency to set Medicaid rates.. Speaker of the House Chris Donovan sat with Hartford Mayor Segarra, and they advocated strongly for the Speaker’s “pooling” bill to allow cities and towns to buy into the state’s health insurance plan. It eventually would allow small businesses and nonprofit organizations to buy in (also part of the SustiNet plan). This bill was vetoed in 2008.

Georgia health insurance John Price, an Aetna insurance local market head, Southeast Region, has been appointed to Commissioner Hudgens health insurance advisory group to help provide the Commissioner with expertise on health insurance issues. Also, the Commissioner of the Department of Community Health announced Friday that the current Managed Medicaid contracts (Wellcare, Amerigroup, Centene) will be extended for 12 months while the new Governor reviews the program.

Ohio health insurance Pooling of Ohio public school district employee health plans will be considered by the General Assembly. A study found that there is the potential for $138 million in savings if the state leverages the greater buying power of pooling 191,000 employees enrolled in 613 public school district health plans. Seventy-two percent of Ohio school districts purchase employee health insurance through consortia, but they are typically composed of 10 or fewer districts and do not result in savings, the study found. The report also calls for the state to find ways to encourage school districts to pursue lower-cost, high-deductible health insurance plans that could reduce district costs up to another 37 percent over current employee health care plans.  As Ohio struggles with the economic downturn and an $8 billion budget deficit, limiting collective bargaining rights is also front and center in the Statehouse so that the Administration ultimately may change the structure of pensions and health care benefits.

Texas health insurance Lt. Gov. David Dewhurst and Sen. Jane Nelson have reintroduced two health care-related bills that died in the House in 2009. One would bring “outcomes-based payments” to Texas’ Medicaid and the Children’s Health Insurance Programs. The other would allow private insurers, major employers and government employees’ insurance plans to experiment with new financial approaches, such as accountable care organizations (ACO). ACOs are an arrangement in which doctors and hospitals share risk, and potential savings, for bringing care costs below targeted levels. The legislation would begin rewarding the state’s health care industry for preventive care and treatments that are coordinated to prevent duplication and waste. The bills will be referred to a committee and debated by both the Senate and House during the current legislative session, ending in late May.

Senators tasked with taking a close look at the Medicaid program got a dose of the difficulties involved in trimming services in a state where services considered optional turn out to be not so optional. They heard testimony on multiple examples of how Medicaid cuts would affect people in the system. Because of the restrictions contained in the federal health care reform law, budget planners have less latitude in where to look for cuts in the Medicaid program. The Senate subcommittee will eventually pass on its recommended budget solutions to the Finance Committee charged with approving an overall budget that makes up a shortfall of more than $20 billion this session.

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