ACA 2.0

Back in January, I posted a story about the ACA subsidy improvements to be included in the then-pending American Rescue Plan (ARP). At the time, I noted what seemed to be a pretty big scoop:

...there's also another small but critical detail included in the table above which escaped my attention last summer in H.R. 1425.

Take a look at the first line of Rep. Underwood's 2019 version (H.R 1868):

  • Over 100.0 percent up to 133.0 percent

Now take a look at the first line under both H.R. 1425 and H.R. 369:

  • Up to 150.0 percent

Notice the difference? I'm not talking about the "up to 150%" part. I'm talking about the removal of the "Over 100.0 percent" part.

If this were to pass the House & Senate and be signed into law by President Biden using this exact language, it would apparently eliminate the Medicaid Gap...albeit with a couple of major caveats.

UPDATE 4/13/21: GAHHH! OK, I screwed up royally on this. It turns out I completely misinterpreted Linda Blumberg's $350 billion estimate of how much S.499 would cost--I thought that was the gross projected 10-year cost without taking into account the impact of eliminating Silver Loading, but it turns out that it's the net cost after taking that into account as well.

As such, most of the premise of this blog post is, sadly, mistaken. My apologies for making such an obvious , bone-headed error.

Having said that, there's still the possibility of up to $196 billion in additional savings elsewhere, so it's still worth discussing the relative costs of both proposals and seeing whether both, or at least parts of both, could still be worked into the American Families Plan. I've reworked the latter portion of this entry to reflect that.

This is mostly an updated version of a post from last week, but there's some important new (potential) developments. Via Amy Lotven of Inside Health Policy:

The White House is expected to roll out the health care priorities for its two-part infrastructure package sometime this Spring, and the health piece potentially could move separately now that the Senate parliamentarian has agreed Democrats have another shot passing their priorities through a simple majority. While there appears to be consensus that the bill will expand, or make permanent, the Affordable Care Act tax credits from the American Rescue Plan, other policies are less clear and will likely depend on the amount of offsets lawmakers can glean from drug-pricing measures.

via Amy Lotven and John Wilkerson of Inside Health Policy:

Pelosi: Drug Pricing May Pay For Health Care Pieces Of Infrastructure Bill

House Speaker Nancy Pelosi (D-CA) said everything is on the table for the next legislative package that is expected to focus on infrastructure improvements and include health care provisions like a permanent increase to the Affordable Care Act tax credits — and she said the package likely will be paid for by tackling prescription drug prices.

...Pelosi said including House Democrats’ drug pricing bill, H.R.3, would pay for $500 billion of the cost of the infrastructure bill, part of which could be used to boost ACA tax credits and make ACA coverage more affordable. The savings also could also be used for other health-related efforts, she said. For example, House Energy & Commerce Chair Frank Pallone (D-NJ) has been working with Rep. Jim Clyburn (D-SC) to expand community health centers and to improve broadband services, which would support telehealth.

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:

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:

Back in late January, Senator Mark Warner of Virginia announced the introduction of a new-ish bill called the Health Care Improvement Act of 2021. Tell me if any of the major provisions look familiar:

  • Capping health care costs on the ACA exchanges
  • Establishing a low-cost public health care option
  • Authorizing the federal government to negotiate prescription drug prices
  • Allowing insurers to offer health care coverage across state boundaries
  • Supporting state-run reinsurance programs
  • Incentivizing states to expand Medicaid
  • Expanding Medicaid eligibility for new moms
  • Simplifying enrollment
  • Increasing Medicaid funding for states with high levels of unemployment
  • Reducing burdens on small businesses

This afternoon, the Congressional Budget Office released their 10-year "score" report of the largest single chunk of the House Democrats version of the American Rescue Plan from the Ways & Means Committee:

Legislation Summary

S. Con. Res. 5, the Concurrent Resolution on the Budget for Fiscal Year 2021, instructed several committees of the House of Representatives to recommend legislative changes that would increase deficits up to a specified amount over the 2021-2030 period. As part of this reconciliation process, the House Committee on Ways and Means approved legislation on February 10 and 11, 2021, with a number of provisions that would increase deficits. The legislation would extend unemployment benefits, establish a pandemic emergency fund, increase subsidies for health insurance, provide cash payments to eligible people, expand several tax credits, and modify rules for pensions, among other provisions designed to mitigate the impact of the COVID-19 pandemic caused by the coronavirus.

Earlier this evening, the House Ways & Means Committee formally published the markup of nine legislative provisions which, if they all survive the process, will make up roughly half of President Biden's proposed $1.9 trillion COVID-19 relief package, aka the American Rescue Plan:

The Ways and Means’ proposals comprise half of the $1.9 trillion Democratic COVID-19 relief package

SPRINGFIELD, MA – Today, House Ways and Means Committee Chairman Richard E. Neal (D-MA) announced the Committee will consider nine legislative proposals under the budget reconciliation instructions this week as the next step in delivering COVID-19 relief to the American people. Beginning on Wednesday, February 10, 2021 at 10:00 a.m. through Friday, February 12, 2021, the Committee will markup proposals spanning from extending unemployment insurance to expanding the child tax credit to delivering another round of direct assistance to struggling Americans.

The other day I posted a detailed look at just how much various households could save in premiums if H.R. 369, Rep. Lauren Underwood's Health Care Affordability Act of 2021, were to be passed and signed into law by President Biden. I used 8 different household examples, and based the savings on the national average 2021 benchmark premium for a single 40-year old, according to the Kaiser Family Foundation.

The households I used include:

UPDATE: Everything below refers to HR 369, but the American Rescue Plan, HR 1319, contains a virtually identical expansion of ACA subsidies...if only for two years.

Note that under HR 1319 (AmRescuePlan), the first year would be retroactive, meaning that current ACA enrollees should receive additional subsidies dating back to January 2021, though I don't know what form that will take...rebate checks, credit towards future premiums or an extra tax refund next spring.

Over the past couple of years, one of the things I've become known for is my obsessive fixation on visually displaying how much various households would save on healthcare premiums if various ACA subsidy-boosting bills were passed compared with the current ACA subsidy structure.

Back on January 14th, I noted that President Biden's proposed $1.9 trillion American Rescue Plan includes a couple of interesting ACA-specific provisions:

Roughly two to three million people lost employer sponsored health insurance between March and September, and even families who have maintained coverage may struggle to pay premiums and afford care. Further, going into this crisis, 30 million people were without coverage, limiting their access to the health care system in the middle of a pandemic. To ensure access to health coverage, President-elect Biden is calling on Congress to subsidize continuation health coverage (COBRA) through the end of September. He is also asking Congress to expand and increase the value of the Premium Tax Credit to lower or eliminate health insurance premiums and ensure enrollees - including those who never had coverage through their jobs - will not pay more than 8.5 percent of their income for coverage.

Together, these policies would reduce premiums for more than ten million people and reduce the ranks of the uninsured by millions more.

Note: This is the second or third time that I'm cribbing a bit from my friend & colleague Andrew Sprung over at Xpostfactoid. If you like my healthcare policy analysis/writing style and follow me on Twitter, you should follow him at @xpostfactoid as well.

Over at Xpostfactoid, Andrew Sprung beat me to the punch by several days with an excellent two-part look at the "ACA 2.0 Hunger Games" scenario.

During the Democratic primary season, I posted a simple graph which boiled down the four major types of healthcare policy overhaul favored by the various Democratic Presidential candidates...which also largely cover the gamut of systems preferred by various Democratic members of the House and Senate.

As I noted a year and a half ago in my analysis of Joe Biden's healthcare policy proposal, two major chunks of his plan are taken straight out of the House Democrats ACA 2.0 bills from 2018 & 2019 and from the Elizabeth Warren's ACA 2.0 bill in the Senate (CHIP, or the Consumer Health Insurance Protection Act). In fact, these two particular proposals were even part of Hillary Clinton's 2016 health plan, and originated way back in 2015 under a proposal by the Urban Institute:

It's been a solid year since Joe Biden rolled out his own official healthcare policy proposal. I did a fairly in-depth writeup on it last summer, but it's the understatement of the year to say that "a lot has changed since then".

The two most obvious developments on this front are 1. Biden has gone from one candidate of two dozen to being the presumptive Democratic Nominee; and 2. The COVID-19 pandemic has completely upended not only the Presidential race but the economy and the entire U.S. healthcare system. A third important (if less consequential) development is that the House has actually passed their own "ACA 2.0" bill in the form of H.R. 1425, the Affordable Care Enhancement Act, which partially overlaps Biden's healthcare plan.

Last evening, over three years after I posted my "If I Ran the Zoo" wish list of recommended improvements for the ACA, the U.S. House of Representatives finally passed H.R. 1425, the Patient Protection & Affordable Care Enhancement Act (#AHEA), which I simply dub "ACA 2.0":

House Democrats on Monday passed a bill that would bolster the Affordable Care Act by hiking premium subsidies and incentivizing states to expand Medicaid.

I wrote up a detailed, step-by-step explainer of all 30 provisions of the ACEA last week, and couldn't be happier to see it finally pass through at least one Congressional body.

Unfortunately...

OK, this surprised me a bit: #HR1425, the Patient Protection & Affordable Care Enhancement Act, has already received a 10-year budgetary impact score from the Congressional Budget Office. I don't think this is a formal score--the whole thing is only five pages and includes minimal text accompanying it, so it might be just a "draft" score or something. I presume that if Mitch McConnell were to shock everyone and actually give it a vote in the Senate (which won't happen), there would likely have to be a second, more elaborate scoring process done by the CBO first. Then again, perhaps not.

Anyway, in a nutshell, the CBO report on the House version of H.R. 1425 comes to the following conclusions regarding the budget impact and other, related results of the bill being implemented nationally. Keep in mind that this assumes that the bill became law and was implemented starting in 2021; the score includes the 10 year period from 2021 - 2030:

TITLE I: Lowering Healthcare Costs & Protecting People w/Pre-Existing Conditions:

OK, I don't know if I "scooped" everyone with my H.R. 1425 explainer yesterday or what, but the House Energy & Commerce Committee just now sent out an official press release announcing the bill, along with a one-page summary, more detailed explainer and the link to the text itself. It's kind of interesting to see what language they use and which sections they emphasize, espeically as compared & contrasted with my own write-up:

Health Committee Chairs Unveil Legislative Package to Make Health Care & Prescription Drugs More Affordable

Legislation Also Expands Access to Health Care, Protects People with Pre-Existing Conditions & Reverses Administration’s Ongoing Sabotage of the ACA

Back in early March (a lifetime ago given the events of the past few months), House Democrats were on the verge of finally voting on a suite of important ACA protections, repairs and improvements which I've long dubbed "ACA 2.0" (the actual title of the first version of the "upgrade suite" bill was ridiculous when it was first introduced in 2018, and the slightly modified version re-introduced in 2019 was somehow even worse, no matter how good the bill itself was).

The game plan was to hold a full floor vote in the House on H.R. 1884 (or possibly a slightly different variant) the week of March 23rd, 2020 to coincide with the 10th Anniversary of the Affordable Care Act itself. This would have made perfect sense both symbolically as well as policywise, as the ACA desperately needs a major upgrade (and it would've needed one even without years of Trump/GOP sabotage, I should note).

Regular readers may have noticed that after a 3-4 month hiatus, I've recently started writing several stories touting "ACA 2.0"-type bills again over the past week or so.

First, last Tuesday, I dusted off my "How much would H.R. 1868 lower YOUR premiums?" series, in which I look at real-world examples of the impact of killing the ACA subsidy cliff (i.e. the 400% FPL income eligibility threshold) and beefing up the underlying subsidy formula in specific parts of the country. Then, on Monday, I wrote an updated explainer of a newer bill, H.R. 6545, an Age-Based subsidy enhancer, which I'm touting as a perfect companion bill to go alongside H.R. 1868.

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.

Over a year ago, I wrote an analysis of H.R.1868, the House Democrats bill that comprises the core of the larger H.R.1884 "ACA 2.0" bill. H.R.1884 includes a suite of about a dozen provisions to protect, repair and strengthen the ACA, but the House Dems also broke the larger piece of legislation down into a dozen smaller bills as well.

Some of these "mini-ACA 2.0" bills only make minor improvements to the law, or make improvements in ways which are important but would take a few years to see obvious results. Others, however, make huge improvements and would be immediately obvious, and of those, the single most dramatic and important one is H.R.1868.

The official title is the "Health Care Affordability Act of 2019", but I just call both it and H.R.1884 (the "Protecting Pre-Existing Conditions and Making Health Care More Affordable Act of 2019") by the much simpler and more accurate moniker "ACA 2.0".

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.

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:

Two years ago, Democratic Congressmen Frank Pallone, Bobby Scott and Richard Neal introduced the awkwardly-titled "Undo Sabotage and Expand Affordability of Health Insurance Act of 2018", which really amounted to a suite of improvements and strengthening of the Affordable Care Act which I simply labelled "ACA 2.0".

At the time it was purely a messaging bill, of course, since the Democrats were in the minority in the House and Senate, as well as obviously not having control of the White House either.

Almost exactly a year later, the situation had changed: Democrats were still out of power in the White House and Senate, but they had flipped the House of Representatives on a promise of working to protect, repair and strengthen the ACA. Sure enough, the same ACA 2.0 bill was re-introduced with a few tweaks and a new, even clunkier name: The Protecting Pre-Existing Conditions and Making Healthcare More Affordable Act.

As healthcare reporter Kimberly Leonard put it at the time:

Last March I wrote an analysis of H.R.1868, the House Democrats bill that comprises the core of the larger H.R.1884 "ACA 2.0" bill. H.R.1884 includes a suite of about a dozen provisions to protect, repair and strengthen the ACA, but the House Dems also broke the larger piece of legislation down into a dozen smaller bills as well.

Some of these "mini-ACA 2.0" bills only make minor improvements to the law, or make improvements in ways which are important but would take a few years to see obvious results. Others, however, make huge improvements and would be immediately obvious, and of those, the single most dramatic and important one is H.R.1868.

The official title is the "Health Care Affordability Act of 2019", but I just call both it and H.R.1884 (the "Protecting Pre-Existing Conditions and Making Health Care More Affordable Act of 2019") by the much simpler and more accurate moniker "ACA 2.0".

Last March I wrote an analysis of H.R.1868, the House Democrats bill that comprises the core of the larger H.R.1884 "ACA 2.0" bill. H.R.1884 includes a suite of about a dozen provisions to protect, repair and strengthen the ACA, but the House Dems also broke the larger piece of legislation down into a dozen smaller bills as well.

Some of these "mini-ACA 2.0" bills only make minor improvements to the law, or make improvements in ways which are important but would take a few years to see obvious results. Others, however, make huge improvements and would be immediately obvious, and of those, the single most dramatic and important one is H.R.1868.

The official title is the "Health Care Affordability Act of 2019", but I just call both it and H.R.1884 (the "Protecting Pre-Existing Conditions and Making Health Care More Affordable Act of 2019") by the much simpler and more accurate moniker "ACA 2.0".

Last March I wrote an analysis of H.R.1868, the House Democrats bill that comprises the core of the larger H.R.1884 "ACA 2.0" bill. H.R.1884 includes a suite of about a dozen provisions to protect, repair and strengthen the ACA, but the House Dems also broke the larger piece of legislation down into a dozen smaller bills as well.

Some of these "mini-ACA 2.0" bills only make minor improvements to the law, or make improvements in ways which are important but would take a few years to see obvious results. Others, however, make huge improvements and would be immediately obvious, and of those, the single most dramatic and important one is H.R.1868.

The official title is the "Health Care Affordability Act of 2019", but I just call both it and H.R.1884 (the "Protecting Pre-Existing Conditions and Making Health Care More Affordable Act of 2019") by the much simpler and more accurate moniker "ACA 2.0".

Last March I wrote an analysis of H.R.1868, the House Democrats bill that comprises the core of the larger H.R.1884 "ACA 2.0" bill. H.R.1884 includes a suite of about a dozen provisions to protect, repair and strengthen the ACA, but the House Dems also broke the larger piece of legislation down into a dozen smaller bills as well.

Some of these "mini-ACA 2.0" bills only make minor improvements to the law, or make improvements in ways which are important but would take a few years to see obvious results. Others, however, make huge improvements and would be immediately obvious, and of those, the single most dramatic and important one is H.R.1868.

The official title is the "Health Care Affordability Act of 2019", but I just call both it and H.R.1884 (the "Protecting Pre-Existing Conditions and Making Health Care More Affordable Act of 2019") by the much simpler and more accurate moniker "ACA 2.0".

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