11 state insurance commissioners send ACA improvement wish list to PE Biden

This is interesting...I just received the following email from the Michigan Dept. of Insurance & Financial Services

Michigan Joins Group of State Insurance Commissioners to Provide ACA Policy Recommendations to President-elect Biden

Anita Fox, Director of the Michigan Department of Insurance and Financial Services (DIFS), has joined a group of state insurance commissioners in a pledge to work with President-elect Joe Biden by providing health policy recommendations to the incoming administration.

The commissioners share President-elect Biden’s vision that no American should have to go without health care coverage. They believe comprehensive and progressive health care is essential to addressing urgent public health priorities, such as the COVID-19 and opioid crises, addressing racial disparities in the health care system, and ensuring enforcement of mental health parity.

“I’m proud to stand with my fellow insurance commissioners to address these critical health care issues with the Biden administration,” said Director Fox. “The State of Michigan is focused on ensuring equitable access to affordable, high quality health care. By addressing these issues with national leaders, we hope to improve outcomes for all Michiganders.”

A letter sent by the group of commissioners detailed six immediate or critical policy recommendations and six longer-term recommendations for the Biden administration to consider.

Immediate policy recommendations

• Ensure immediate access to the federal marketplace, Healthcare.gov, through a special enrollment period.

This one is noteworthy mostly because six of the eleven states which sent the letter operate their own ACA exchanges, all of which either extended their own Open Enrollment Period beyond the 12/15 deadline, enacted their own COVID-19 SEP, or both.

• Provide immediate relief from Affordable Care Act (ACA) subsidy clawbacks created by COVID-19 uncertainty.

At first I assumed this referred to the APTC Forms 1095-A/8962 reconciliation issue which has already been resolved, but it turns out they're talking about the confusing-as-hell MAGI calculations caused by last spring's CARES COVID-19 relief act. The short version is that the one-time $1,200 checks as well as the $600/week unemployment insurance payments caused a lot of people's actual incomes to increase beyond what it otherwise would've been, but the rules for how much of that extra money "counts" for purposes of either Medicaid eligibility or ACA subsidies caused a bit of a mess for some of the state exchanges as well as for many of the enrollees themselves.

• Provide clarity on COVID-19 testing coverage requirements, especially in regard to tests that are ordered as part of state-based contact tracing efforts.
• Partner with states in actively focusing on programs and practices that address the needs of historically marginalized communities.
• Address problematic elements of the recently proposed Notice of Benefit and Payment Parameters (NBPP) for Plan Year 2022.

I wrote about this a few weeks ago and plan on a follow-up later today or tomorrow regarding the actual Public Comment process. The signers are strongly opposed to several of the same NBPP proposals that I am.

• Allow flexibility for states aiming to pursue progressive policy aims by empowering them to apply for ACA innovation waivers beyond reinsurance.

Longer-term policy priorities

• Reverse policies, such as the weakening of non-discrimination protections and the public charge rule, that undermine the ACA and deny health care coverage to many people.

• Encourage both people and small businesses to enroll in ACA programs, and stop encouraging enrollment in insurance plans that do not provide the ACA’s most critical consumer protections.

Again: #ShortAssPlans may be a necessary evil until the ACA subsidy cliff is killed, but they sure as hell shouldn't be actively encouraged by the federal government.

• Improve income counting rules to allow consumers greater flexibility.

This one confused me, but the letter's explanation makes total sense:

An additional area of flexibility for states, where increased clarity from IRS would be appreciated, is clarifying by rule that state-funded and administered subsidies that increase health insurance affordability are not counted as income for modified adjusted gross income calculations or for federal tax filings. Finally, federal agencies should consider strategies to improve data sharing with states where that data would be used to support shared policy aims. For example, any assistance that can be provided to all for sharing data with state all-payer claims databases would assist those states who are focused on health care cost-control and transformative payment reform measures.

California, New Jersey, Vermont and Washington State all provide their own subsidies to ACA enrollees on top of the federal APTC assistance. Apparently right now, there's confusion about whether those state subsidies are themselves counted as part of enrollee income for purposes of receiving the federal subsidies (as well as federal taxes). This is honestly the first time I've heard anyone mention this, but I can see how big of a problem it could be.

• Extend premium tax credits to Deferred Action for Childhood Arrivals (DACA) recipients so that legally present noncitizens have access to health care coverage.

Undocumented immigrants aren't allowed to enroll in ACA exchange plans (even at full price, which is pretty stupid in my book), but most categories of legally present immigrants are. This would add DREAMers to the list, which is the right thing to do.

• Modernize Department of Labor oversight of the Employee Retirement Income Security Act to ensure all health insurance coverage is held to similar standards.

Short version: Some employer-sponsored health insurance is regulated by the states, but the self-funded employer coverage subject to ERISA (the Employee Retirement Income Security Act) is under federal jurisdiction. These commissioners are asking the Biden Administration to modify Labor Dept. ERISA regulations to beef up enforcement of things like mental health parity and enrollee complaints; crack down on Association Health Plans & shady/fraudulent players in that field; and to back off on letting employers participate in state-level public options and other progressive healthcare policies.

• Consider a national reinsurance program to stabilize health insurance markets and improve affordability of health insurance coverage.

The ACA included a (moderate) national reinsurance program when the exchanges launched in 2014, but it automatically sunsetted after three years (this was a big part of the reason for the dramatic premium spikes in 2017). Since then, over a dozen states have implemented their own reinsurance programs to cut down unsubsidized premium rates via the ACA's 1332 waiver provision, but most haven't, and these programs are actually sort of a bit of a "rob Peter to pay Paul" situation, because they actually rely on federal ACA subsidies being reduced for those receiving them.

Reinstating the federal reinsurance program would likely require Congressional legislation, so it's not something Biden could do on his own, but their point is to consider it as one of the fallback positions in the event his full healthcare proposal doesn't go through, since reinsurance seems to have a lot of bipartisan support.

Enacting these policy recommendations will provide immediate relief to many Americans affected by the COVID-19 crisis, provide states with flexibility to strengthen health insurance markets, remove discriminatory barriers to health coverage, protect the coverage needs of Americans with pre-existing conditions, and ensure comprehensive health insurance access is available to all Americans.

The following state insurance commissioners developed these recommendations and are committed to working with the Biden administration on its national health care plan:

• Commissioner Ricardo Lara, California
• Commissioner Michael Conway, Colorado
• Commissioner Trinidad Navarro, Delaware
• Commissioner Colin M. Hayashida, Hawaii
• Director Anita G. Fox, Michigan
• Temporary Commissioner Grace Arnold, Minnesota
• Commissioner Andrew R. Stolfi, Oregon
• Commissioner Jessica K. Altman, Pennsylvania
• Health Insurance Commissioner Marie Ganim, Rhode Island
• Commissioner Mike Kreidler, Washington
• Commissioner Mark Afable, Wisconsin