For several years now, I've been urging Congress to upgrade the Affordable Care Act via a series of major improvements. Most notable among these is the need to #KillTheCliff...that is, to eliminate the so-called "Subsidy Cliff" which kicks in for ACA individual market enrollees who earn more than 400% of the Federal Poverty Line (roughly $50,000 for a single adult or $103,000 for a family of four).

As I've explained many tmes, the ACA's subsidy structure works pretty well for those earning between 100 - 200% FPL, and is at least acceptable for those earning 200 - 400% FPL (in fact, thanks to #SilverLoading, it works quite well for most of that population as well). The real problem kicks in above 400% FPL (and to a lesser extent below 138% FPL for those living in the 14 states which still haven't expanded Medicaid). In addition, the subsidy formula still doesn't make policies truly affordable for many of those receiving them.

In short, both the upper- & lower-bound Subsidy Cliffs need to be eliminated, and the underlying formula needs to be strengthened as well.

Besides effectively baking in a more-generous version of H.R. 1868 (Rep. Lauren Underwood's #KilltheCliff bill which I've been pushing for so hard for over a year now), the House Democrats' "Take Responsibility for Workers and Families Act" coronavirus stimulus/relief bill also includes some other important ACA-related provisions. Some of these are temporary, others would be permanent.

For a couple of weeks now, I've been posting constant updates as one state-based ACA exchange after another has announced a COVID-19-specific Special Enrollment Period in light of the ongoing pandemic crisis. Until now, though, there's been two ACA exchanges which haven't made such an announcement. One is the Big One, HealthCare.Gov, which hosts a whopping 38 states and which is facing increasing pressure to do so.

The other...is Idaho. Specifically, Your Health Idaho, the state's ACA exchange.

Dave Anderson brought this to my attention in the big "Take Responsibility for Workers and Families Act" coronavirus stimulus/relief bill being rolled out today as an alternative to the Senate Republican's "$500 billion corporate slush fund" bill being pushed by Mitch McConnell.

If you scroll allllllllll the way down to Pages 1,088 - 1,090, there are two provisions which relate directly to the Affordable Care Act's Advance Premium Tax Credits for exchange enrollees:

SEC. 103. RESTORATION OF LIMITATIONS ON RECONCILIATION OF TAX CREDITS FOR COVERAGE UNDER A QUALIFIED HEALTH PLAN WITH ADVANCE PAYMENTS OF SUCH CREDIT.

(a) IN GENERAL.—Section 36B(f)(2)(B)(i) of the Internal Revenue Code of 1986 is amended to read as follows:

photo courtesy of Michelle Mills

Today is the 10th Anniversary of the signing of the Patient Protection & Affordable Care Act. On March 23rd, 2010, President Barack Obama signed the bill into law, although it would be another 3 years and 9 months before most of the major provisions would go into effect: ACA exchange policies, Advance Premium Tax Credits and Cost Sharing Reduction subsidies, Medicaid expansion in most states (although a few got an early start via special waivers and conversion of existing programs), and so forth.

You may notice that I referred to it as the Patient Protection & Affordable Care Act. I, like most people, tend to shorthand the name as simply "the Affordable Care Act" or "the ACA", but the truth is that it's the patient protection part which received the most attention during the Great ACA Repeal Debacle of 2017...and which has once again come front & center in the spring of 2020.

I realize this may seem more than a little trite given the ongoing and everpresent COVID-19 pandemic...and it might be particularly so given that a dozen state-based ACA exchanges have just launched Special Enrollment Periods to help address the crisis (with HealthCare.Gov likely to follow them any day now).

Even so, the 10th Anniversary of the signing of the Patient Protection & Affordable Care Act is coming up this Monday, so I figured I should take a moment to note the continuing trendline between the Federally Facilitated Marketplace (FFM) (HealthCare.Gov) and the State-based Marketplaces (SBMs). There have been as many as 15 or as few as 12 depending on the year.

The first table below lists the official number of Qualified Health Plans which were selected by Americans during the official Open Enrollment Periods for the first seven years they've occured. The blue cells represent states which operated their own full SBMs that year. This has changed over the years as follows:

Three days ago, in my "Calls growing for CMS to offer COVID-19 Special Enrollment Period via HealthCare.Gov" post, I noted that:

There's only two reasons why limited-time Open Enrollment Periods exist in the first place:

1. To help prevent people from gaming the system & causing premiums to skyrocket by waiting until they're sick/injured to sign up

2. To help goad/spur people into action (deadlines are proven to be very effective at getting people off their butts)

The thing is, this is a pandemic. "Ensuring a stable risk pool" isn't exactly a top priority for anyone at this particular moment, and the economic consequences of this disaster are going to be rampant for quite awhile no matter what anyway. Right now the top priority should be making certain as many people are covered as possible. And "deadly global pandemic" is likely to be pretty "inspirational", I'd imagine.

This just in via MNsure...

MNsure Announces Special Enrollment Period for Uninsured Minnesotans in Response to Growing COVID-19 Concerns

ST. PAUL, Minn.—Today MNsure announced a 30-day special enrollment period (SEP) for qualified individuals who are currently without insurance, in response to the potential growth of coronavirus (COVID-19) cases. This SEP that begins Monday, March 23, and runs through April 21, will allow uninsured individuals 30 days to enroll in health insurance coverage through MNsure.org.

“As more cases of COVID-19 are diagnosed throughout the state, we want to make sure every Minnesotan has the security of health insurance to ensure they can get the care they need if they contract this serious illness,” said MNsure CEO Nate Clark. “Uninsured Minnesotans can come to MNsure.org to sign up for coverage.”

Governor Tim Walz recently declared a peacetime emergency in response to the pandemic and stressed the importance of all Minnesotans to take care to avoid the spread of COVID-19.

California Responds to COVID-19 Emergency by Providing Path to Coverage for Millions of Californians

  • Covered California Expands Special Enrollment and Medi-Cal Seeks Waivers to Encourage Coverage
  • Effective immediately, anyone uninsured and eligible to enroll in health care coverage through Covered California can sign up through the end of June.
  • The Department of Health Care Services announces new steps to help those eligible for Medi-Cal sign up easily and get immediate coverage.
  • The moves come amid widespread disruption in the lives and livelihoods of Californians as public health officials seek to reduce the spread of COVID-19.
  • All medically necessary screening and testing for COVID-19 are free of charge, and all health plans available through Medi-Cal and Covered California offer telehealth options.
  • These actions build on increased state subsidies and the implementation of a state penalty, both of which took effect in January 2020

No one has been shouting from the rooftops louder than I have for HHS Secretary Alex Azar or CMS Administrator Seema Verma to join nearly all of the state-based ACA exchanges in announcing an official Special Enrollment Period (SEP) in light of the ongoing Coronavirus pandemic, and I'm still urging them to do so as soon as possible. The federal ACA exchange, HealthCare.Gov, hosts ACA enrollment for 38 states representing around 75% of the national population, so this is a pretty big deal.

Having said that, it's important to keep in mind that even without a COVID-19-specific SEP, many people already qualify to enroll in ACA-compliant healthcare coverage anyway, whether they're currently uninsured or because they're about to be...or because their personal circumstances are about to change. And none of these have anything to do with the COVID-19 crisis, although it's certainly going to cause a whole lot more people to qualify for two of those changes:

Special Enrollment Period (SEP)

This Just In via Vermont Health Connect...

The State of Vermont has made temporary changes to assure that Vermonters have access to health insurance. Please visit https://t.co/dXz4Cd2yQm for more information

— VT Health Connect (@VTHealthConnect) March 20, 2020

OK...that's about as vague and understated as you can get. Clicking the link doesn't make it any more obvious:

Stay informed and protect your health.

Last week I noted that House Democrats introduced the Families First Coronavirus Response Act, which includes a whole mess of important measures to deal with the economic and public health crisis fallout of the global pandemic. This act is by no means all that's needed, but it's an important start. The bill included, among other things, additional/emergency funding for:

via CMS:

Earlier today at the White House Task Force Press Briefing, the Centers for Medicare & Medicaid Services (CMS) announced that all elective surgeries, non-essential medical, surgical, and dental procedures be delayed during the 2019 Novel Coronavirus (COVID-19) outbreak.

As more healthcare providers are increasingly being asked to assist with the COVID-19 response, it is critical that they consider whether non-essential surgeries and procedures can be delayed so they can preserve personal protective equipment (PPE), beds, and ventilators. 

“The reality is clear and the stakes are high: we need to preserve personal protective equipment for those on the front lines of this fight,” said CMS Administrator Seema Verma.

I've only written about Montana State Auditor (which includes acting as the Insurance Commissioner, as far as I can tell) Matt Rosendale a couple of times before. The first was in October/November 2017, when he pulled a cynical, disingenuous dick move by deliberately framing a non-profit insurance carrier into losing money for purely political reasons:

Montana commissioner chides insurance companies for raising rates, despite earlier offers to help

BOZEMAN — Montana's insurance commissioner chided two companies for raising rates on health insurance policies offered under the Affordable Care Act after federal subsidies ended, despite earlier telling them they could modify their rates if circumstances changed, the Bozeman Daily Chronicle reported.

...Matt Rosendale said he was "extremely disheartened" that PacificSource and the Co-op increased their premiums, adding that he had been assured by the companies that with or without the cost-sharing reduction payments they would be able to honor the rates they first submitted.

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