February 1, 2013
ACA Implementation: MLR & More
The Commonwealth Fund has recently reported on how states are lagging in implementing consumer protection aspects of the ACA. In case you are looking for a comprehensive overview of the options open to a state as it implements the MLR provisisons of the ACA, check out my colleague Tara Adams Ragone's policy brief "The Affordable Care Act and Medical Loss Ratios: Federal and State Methodologies." Though the piece focuses on New Jersey, its structure suggests the issues that will come up for many other states:
As part of sweeping health care reform in 2010, Congress established MLR requirements for health insurance issuers offering coverage in the group and individual health insurance markets, including grandfathered but not self-insured plans, hoping to increase the value consumers receive for their premiums and to improve transparency. Medical loss ratio refers to a measure of the percentage of premium dollars that a health insurance company spends on health care as distinguished from administrative expenses and profit, including advertising, marketing, overhead, salaries, and bonuses. Prior to the ACA, some states but not the Federal government regulated loss ratios. The new Federal MLR law, which went into effect on January 1, 2011, for the first time established a national MLR standard, which varies from existing state MLR requirements in important ways.
This Policy Brief analyzes the new Federal MLR requirements and how they intersect with and affect New Jersey law and its insurance markets. After providing background on medical loss ratios and highlighting the major similarities and differences between the existing Federal and New Jersey MLR regulatory schemes, this Brief examines several requirements and policy options that New Jersey must consider as it implements the Federal requirements. This Brief also includes appendices that provide more extensive details regarding the components of the Federal MLR requirements, New Jersey’s MLR legal structure, and research regarding experiences with loss ratios nationally and in New Jersey, pre- and post-the ACA.
My former student Ina Ilin-Schneider has also posted on the MLR, after authoring a very interesting paper on the state waivers granted (and denied) by HHS.
Finally, a quick note to recommend Ann Marie Marciarille's several recent posts at PrawfsBlawg on ACA implementation and health policy generally. It's hard to write about these topics gracefully and for a general audience, while conveying the expertise of a scholar. I think of her posts as real models on both counts.
January 31, 2013
Penultimate poor and the individual mandate
The Department of Health and Human Services just released regulations that address, to a degree, the plight of the poor in states that refuse to expand their Medicaid populations. The ACA's original design made it so that the Medicaid expansion would cover childless adults up to 133% of the federal poverty level, and others who obtain health insurance through exchanges would be eligible for a tax credit if they earned between 100% and 400% of the FPL. After NFIB v. Sebelius rendered the mandatory expansion an option, some states have declared that they will not expand their Medicaid programs, thus leaving people under 100% of the FPL subject to the individal mandate but too poor to afford private coverage, even with tax credits. Many states cover childless adults who are extremely poor (e.g., West Virginia covers those who earn up to 17% of the FPL), and people earning above 100% of the FPL will receive tax credits - but we have a gap for people who are very poor but will not be able to enroll in Medicaid in non-participating states.
So, keep an eye out for the new regulations, in which HHS clarifies that the individual mandate does not apply to people who are eligible for Medicaid but barred from entering the program because they live in states that have opted out of the expansion. While the clarification is expected (given the hardship exception that already exists for the individual mandate), it is important to know that HHS intends to protect people from their states' decisions. (How's that for turning federalism on its head?)
Unfortunately, the regulation does not and cannot address the bigger problem: getting the penultimate poor into health insurance. Though they will be exempt from the penalty for lack of insurance, they will not have a health insurance home either, thereby denying them much-needed consistent access to the healthcare market. Congress must either amend the ACA in light of NFIB or produce new legislation addressing this coverage gap.
January 30, 2013
Euthanasia in Europe Re-Redux
On January 10, in Fleming v. Ireland, the Irish High Court rejected the argument that assisted suicide should be legally permitted as a right of personal autonomy. Explicitly disagreeing with the Canadian court in Carter v. Canada, the Court concluded that the risks of abuse were simply too great. Interestingly, however, the Court also signaled that the Director of Public Prosecutions may exercise discretion not to prosecute in appropriate cases of assisted death. The Court opined that it "feels sure that the Director in this of all cases would exercise her discretion as whether to prosecute or not. This approach leaves the legislative ban intact while ensuring that the Director is afforded the fullest opportunity to consider what she may think are the special and extenuating factors arising from the harrowing experiences being endured by the plaintiff."LPF]
January 29, 2013
Health Care Reform in Vermont--The Next Wave?
While most of the country continues to tie itself in knots agonizing over the Affordable Care Act, debating whether it is a good or bad thing, deciding whether it is truly a "government take-over" of health care, and keeping the courts and government bureaucrats busy responding to the endless questions about the law and its implementation, another small New England state may be acting as the laboratory for the next wave of health care reform (remember, Massachusetts was the model for the ACA). In 2011, Vermont passed a law authorizing the creation of a universal single-payer health insurance system, to be known as "Green Mountain Care" (the current name of the state's public programs, such as Medicaid), According to the Associated Press, this small state next door to Canada wants something closer to the Canadian health-care system for its citizens, rather than the hodge-podge of coverage options that Americans seem to treasure. As a resident of another state that borders Canada, where I hear stories about Canadians coming to the United States to get medical treatment that they would not be able to receive as quickly in Canada, as well as Canadians residing in the United States returning to Canada to get medical treatments that they cannot get at all in the United States because they can't get insurance or can't afford to pay for them privately, I find Vermont's decision to emulate a Canadian-style system interesting. The Vermont law lists as its purpose "to provide, as a public good, comprehensive, affordable, high-quality, publicly financed health care coverage for all Vermont residents in a seamless and equitable manner regardless of income, assets, health status, or availability of other health coverage." Clearly, Vermont lawmakers decided that the possible inconveniences of waiting lists and delays were outweighed by the evils of being unable to get treatment at all. It's a courageous decision, and it will be interesting to see how it unfolds.
The Vermont system can't be implemented until 2017, because the state will require a waiver from the ACA, and those won't be available until 2017. Nevertheless, the governor has been under pressure to explain how much the system will cost and how it will be financed, and last week, Governor Shumlin released a report that said that the state's share of the cost of the new system will be $1.6 billion, out of a total cost of $3.5 billion. The difference will presumably be covered by federal contributions and assorted private payments. Although this sounds scary, the report notes that most individuals and employers would no longer be buying private health insurance, and that would result in a savings of $1.9 billion. The major criticism of the system is coing from people who say the cost is simply too high.
Will the Vermont experimentt be the forerunner of the next wave--a single-payer health system in the United States? Or is the cost really too high? We will have to stay tuned.