Prepare Thyself: ACA 2.0 is happening. (Part 3 of 3)

On Monday I noted that in the wake of the passage and signing of HR 1319 (the American Rescue Plan, or ARP), which includes a dramatic (if time-limited) upgrade & expansion of ACA individual market subsidies, Senate Democrats are hard at work pushing for several other important bills to make President Biden's larger healthcare policy vision a reality on a permanent basis.

The three bills I discussed in Part 1 are:

• Sen. Mark Warner's Health Care Improvement Act of 2021 (S.352)
• Sen. Michael Bennet & Sen. Tim Kaine's re-introduced "Medicare X" Act (S.386, I believe)
• Sen. Jeanne Shaheen's Improving Health Care Affordability Act (S.499)

Of the three, the one which seems most likely to actually have a shot at passing both the House and Senate and being signed into law by President Biden during the 2021 - 2022 legislative session is Sen. Shaheen's S.499, which would:

• Permanently codify the 8.5% maximum cap on ACA benchmark Silver plan premiums;
• Permanently codify the beefed-up subsidy formula below the 8.5% threshold;
• Upgrade the ACA individual market benchmark plan from Silver to Gold;
• Expand the ACA's CSR subsidy structure from the current 250% FPL threshold to 400% FPL;
• Upgrade the CSR formula so that all enrollees earning less than 400% FPL would qualify for a Platinum or Gold Plus plan; and...
• Pay for a large chunk of the above by formally appropriating CSR reimbursement funds.

If S.499 were to become law, it would check off two major provisions of Pres. Biden's larger proposal.

However...there's a bunch of other stuff on the ACA 2.0 checklist as well, and the House Democrats are also hard at work on them. Behold, the House Energy & Commerce Committee's hearing scheduled for next Tuesday, March 23rd at 11am:

The Subcommittee on Health of the Committee on Energy and Commerce will hold a legislative hearing on Tuesday, March 23, 2021, at 11 a.m. via Cisco Webex. The hearing is entitled, "Building on the ACA: Legislation to Expand Health Coverage and Lower Costs."

• H.R. 1790, H.R. 1796, H.R. 1872, H.R. 1874, H.R. 1875, H.R. 1878, H.R. 1890, H.R. 1896, H.R. 340, H.R. 1738, H.R. 1784, H.R. 1025, H.R. 66, H.R. 1791, H.R. 1888, H.R. 1717, H.R.1880 and H.R. 1390

That's right...they'll be having a marathon hearing to discuss not just one or two bills, but eighteen of them. Two years ago, the House passed a similar, but smaller bundle of seven standalone bills as a package; this strikes me as being pretty much the same thing, with three important differences: First, there's more than twice as many mini-bills included; second, the ARP has already passed, which could help grease the skids. And third, the Dems now hold a trifecta in the House, Senate (just barely) and White House.

Some of 18 bills above are more significant than others, and some of them don't even have a formal title yet. There's no guarantee that all of them will make it out of committee or through the full House, of course, and if/when they make it to the Senate side, there's obviously the filibuster situation to contend with...but it's a start.

In Part 2, I looked at the first 9 of these bills. Today I'm tackling the other 9:

• H.R. 1738, the "Stabilize Medicaid and CHIP Coverage Act"

Depending on the state and their status many Medicaid and CHIP enrollees have to prove that they're still eligible for these programs each and every month. This causes a tremendous amount of extra paperwork/red tape, while also tending to discourage enrollment due to the ongoing hassle of having to keep up on the part of the enrollees. While some people obviously see their fortunes improve over the course of the year, this is more than cancelled out by the extra administrative overhead.

HR 1738, sponsored by Rep. Debbie Dingell (MI-12), would require both those deemed eligible to enroll in either Medicaid or CHIP to remain eligible for 12 months after the first month they're enrolled.

• H.R. 1784, the "Medicaid Report on Expansion of Access to Coverage for Health Care Act" or the "Medicaid REACH Act"

This bill, sponsored by Rep. Lloyd Doggett (TX-35), would significantly strengthen Medicaid reporting requirements for states which have refused to expand Medicaid under the ACA. Basically, it would reduce federal funding by up to 1.5 points per year if a non-expansion state doesn't provide regular data on the estimated number of uninsured residents (including demographic breakouts of that population), how many of them would be eligible for Medicaid if the state were to expand the program; an updated list of what the income eligibility thresholds are for the groups which are eligible for Medicaid in that state; and how much uncompensated care hospitals in the state rack up, as well as how much is paid each year.

• H.R. 1025, the "Kids' Access to Primary Care Act of 2021"

This is another rare bipartisan bill: It's cosponsored by Dem Reps Kim Schrier (WA-08) and Kathy Castor (FL-14) as well as GOP Rep. Brian Fitzpatrick (PA-01). The bill would extend the policy of requiring Medicaid to pay primary care physicians no less than Medicare rates for the same services. I don't see an end date, so it sounds like this would make that policy permanent, but I could be wrong about that.

• H.R. 66, the "Comprehensive Access to Robust Insurance Now Guaranteed for Kids Act" or the "CARING for Kids Act"

CHIP is one of those programs which is usually only funded for 4-5 years at a time. This has allowed it to become a bargaining chip, most recently in 2018 when the GOP Congress decided to hold it hostage for awhile. HR 66 is another bipartisan bill, coming from GOP Rep. Vern Buchanan (FL-16_ and Dem. Rep. Lucy McBath (GA-06).would permanently fund the Children's Health Insurance Program (CHIP), which is currently only funded through 2027.

• H.R. 1791, the "Children's Health Insurance Program Permanency (CHIPP) Act"

Hmmm...I can't find the actual text or even a full description of this bill, but it sounds pretty much identical to HR 66 above. This version was introduced by Rep. Nanette Diaz Barragan (CA-44).

• H.R. 1888, the "Improving Access to Indian Health Services Act"

Introduced by Rep. Raul Ruiz (CA-36). The only description I can find is that it would "require a Federal medical assistance percentage (FMAP) of 100 percent for Indian health care providers, and for other purposes." I have no idea what the current FMAP is for Native American providers (I assume this only applies to those operating on reservations)...I assume it varies depending on the FMAP of the state that the reservation is encompassed by. It sounds like this would require the feds to cover 100% of their reimbursement rates, which I guess makes sense since they're supposed to be federal reservations.

Update: They've posted the legislative text now. I think the current situation is that it's already 100% FMAP for facilities located within a reservation, but this would also expand it to Native American tribal member providers working outside of the reservations, as well as clinics/etc owned by tribal members which are located outside.

• H.R. 1717, To To amend title XIX of the Social Security Act to make permanent the protections under Medicaid for recipients of home and community-based services against spousal impoverishment.

Again, no text or full description, but I wrote about "spousal impoverishment" back in December:

The expense of nursing home care — which ranges from $5,000 to $8,000 a month or more — can rapidly deplete the lifetime savings of elderly couples. In 1988, Congress enacted provisions to prevent what has come to be called "spousal impoverishment," leaving the spouse who is still living at home in the community with little or no income or resources. These provisions help ensure that this situation will not occur and that community spouses are able to live out their lives with independence and dignity.

Under the Medicaid spousal impoverishment provisions, a certain amount of the couple's combined resources is protected for the spouse living in the community. Depending on how much of his or her own income the community spouse actually has, a certain amount of income belonging to the spouse in the institution can also be set aside for the community spouse's use.

The December COVID bill bumped the deadline for this bill out from 2020 to 2023. HR 1717 would make it permanent, which makes sense (I can't fathom why it would've had an expiration date in the first place). This bill is another bipartisan one, with GOP Rep. Fred Upton (MI-06) as the lead sponsor and MI-12 Rep. Debbie Dingell as a co-sponsor.

• H.R.1880 - To amend the Deficit Reduction Act of 2005 to make permanent the Money Follows the Person Rebalancing Demonstration.

Also introduced by Rep. Dingell (MI-12), this would permanently enable the MFP program...

...supports state efforts for rebalancing their long-term services and supports system so that individuals have a choice of where they live and receive services. From the start of the program in 2008 through the end of 2019, states have transitioned 101,540 people to community living under MFP.

MFP Program Goals

• Increase the use of home and community-based services (HCBS) and reduce the use of institutionally-based services
• Eliminate barriers in state law, state Medicaid plans, and state budgets that restrict the use of Medicaid funds to enable Medicaid-eligible individuals to receive support for appropriate and necessary long-term services and supports in the settings of their choice
• Strengthen the ability of Medicaid programs to provide HCBS to people who choose to transition out of institutions
• Put procedures in place to provide quality assurance and improve HCBS

• H.R. 1390, the "Children's Health Insurance Program Pandemic Enhancement and Relief Act" or the "CHIPPER Act"

Finally, this bill from Rep. Susan Wild (PA-07) would...well, "increase support for State Children's Health Insurance programs during the COVID-19 emergency." There's no text or full description, so I'm really not sure what it would do specifically beyond presumably providing additional funding for CHIP and other children's health programs during the COVID pandemic.

Update: OK, they've posted the actual legislative text for HR 1390. Sure enough, it appears to beef up federal funding of CHIP for a two-year period from 2021 - 2022.

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WHEW! There you have it: All 18 bills summarized. I should note that some of these aren't directly related to the ACA itself, but even those which aren't are indirectly connected to it. I don't know how many of these will actually pass the House, and of course there's no way of knowing what'll happen to them in the Senate if they do. Some will likely be rolled into a larger package healthcare bill...or perhaps they'll be sprinkled into the Big Fat Infrastructure Bill which the Biden Administration is hoping to pass later this summer. So much depends on the ongoing filibuster reform drama.

Anyway, stay tuned!