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Todays's ACA Forecast: More Uncertainty from Washington

September 12, 2017

With the most recent repeal/replace failure in Congress, state lawmakers should stop waiting on Washington to “do something” about healthcare. Congressional action, no matter what that action looks like, is unlikely to address the unmet Obamacare promises of delivering healthcare access and affordability.

Furthermore, an upcoming decision from President Trump on what do about the Affordable Care Act’s (ACA) cost-sharing reductions could make the future of the ACA even more chaotic.

More uncertainty is looming

Cost-sharing subsidies totaling about $7 billion to reduce out-of-pocket costs, such as co-payments and deductibles, for individuals and families below 250 percent of poverty. The cost-reduction payments have not only been controversial, but they are also at the center of a legal battle.

In 2014, House Republicans filed a lawsuit to end the payments since the funds were paid but never appropriated by Congress. The court sided with the House, but the Obama administration appealed. The Trump administration is expected to announce a decision on whether or not to drop the appeal this week. There are several scenarios that could play out, but it is likely that this issue will remain in the courts.

These payments will not only impact potential premiums for the plan year 2018, but they may determine whether there will be a continued exodus of insurers from the ACA exchanges. If these subsidies do not continue, exchange insurers may decide to exit the exchange markets. Their contracts with the U.S. Department of Health and Human Services (HHS) stipulate that, should subsidies end, they can immediately exit the market.

Insurers that do remain are expected to raise their premiums even higher to cover the lost cost-sharing subsidies. That would be in addition to the already high anticipating premium increases.

Fewer insurers and higher premiums

Insurers have already been fleeing the exchange markets over the past couple of years. Last year, Pinal County, Arizona was in danger of being the only bare county in the U.S. The state Department of Insurance scrambled to bring in an insurer before open enrollment began.

Dozens of counties are already expected to be “bare” for the 2018 plan year with more than one-thousand having a single remaining exchange insurer. State insurance commissioners are now scrambling to get those bare counties covered.

For most counties, premium increases will be steep. Average premium increases will be in the neighborhood of 20 percent. Premium prices are due by August 16, and with the prospect of uncertainty looming well past that deadline, there is a good reason to believe that many markets will see rates rise even higher.

What states can do

But regardless of what happens next in Washington, state-level policymakers should continue to strive for meaningful healthcare reforms to impact the cost of care in their states. Reforms such as expanding state scope of practice laws, rescinding Certificate of Need laws, and protecting charity care efforts can impact healthcare access and cost of services.

Scope of practice: Healthcare practitioners should be allowed to practice at the top of their education and training. For example, pharmacists are not allowed to administer vaccinations in some states despite the fact that pharmacists are well qualified to undertake this task with minimal risks to the patient. Furthermore, rolling back scope-of-practice laws can help alleviate the shortage of healthcare providers, especially in rural areas.

Certificate of Need: Facilities and services should be available on the basis of able and willing providers, not on government-sanctioned boards deciding who should be allowed to serve patients. Rather than restraining costs, Certificate-of-Need laws consistently restrict healthcare access and competition.

Charity care: States can also enact Good Samaritan laws that provide legal protection for those offering healthcare services. These protections can be particularly helpful for allowing charity groups to provide large-scale charity operations and for medical personnel wishing to assist in response to natural disasters.

Direct Primary Care: Direct Primary Care, or DPC, is an innovative healthcare arrangement that allows patients or their employers to contract with a provider for primary care medical services directly. This allows patients to directly and more immediately access non-emergency care and, under many arrangements, allows them to do so as many times as needed at no additional cost.

Unlike a typical healthcare arrangement, DPC operates independently of traditional health insurance. But in some states, decades-old regulations originally designed to govern the health insurance market are being imposed on these arrangements, stifling the potential growth of this new healthcare option.

Telemedicine: In many states, it is legal for doctors to prescribe treatments through the Internet without ever meeting a patient in person. Unfortunately, there is an increasing push in some states to impose new regulatory burdens on practitioners that have no significant bearing on patient safety. For example, some states have adopted distinct clinical practice rules for these new services that are more onerous than those imposed on traditional providers.

Promote access and affordability

While there is no silver bullet to the problems facing the American healthcare system, the answer to the nation’s healthcare woes does not lie in bigger bureaucracies and less accountability. That is why state lawmakers should not wait on Washington. They should begin work on meeting the unmet goals of the ACA, promoting healthcare access and affordability.



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