Tagged Trump Administration

Need Health Insurance? The Deadline Is Dec. 15

The woman arrived at the University of South Florida’s navigator office in Tampa a few weeks ago with a 40-page document describing a short-term health insurance plan she was considering. She was uncomfortable with what the broker had said about the coverage, she told Jodi Ray, a health insurance navigator who helps people enroll in coverage, and she wanted help understanding it.

The document was confusing, according to Ray, who oversees Covering Florida, the state’s navigator program. It was hard to decipher which services would be covered.

“It was like a bunch of puzzle pieces,” she said.

Encouraged by her wife, the woman eventually opted instead for a marketplace plan with comprehensive benefits.

The annual open-enrollment period for people who buy their own insurance on the Affordable Care Act’s marketplaces ends Dec. 15 in most states. Enrollment in states that use the federal healthcare.gov platform has been sluggish this year compared to last. From Nov. 1 through Dec. 1, about 3.2 million people had chosen plans for 2019. Compared with the previous year, that’s about 400,000 fewer, or a drop of just over 11 percent.

The wider availability of short-term plans is one big change that has set this year’s apart from past sign-up periods.

Another is the elimination of the penalty for not having health insurance starting next year. The Congressional Budget Office has estimated that as many as 3 million people who buy their own coverage may give it up when they don’t face a tax penalty.  But experts who have studied health insurance enrollment say that surveys so far indicate that the penalty hasn’t typically been the pivotal factor in people’s decision on whether to buy insurance.

They also caution against reading too much into the preliminary enrollment totals.

“There typically is a surge in enrollment at the end,” said Sabrina Corlette, research professor at Georgetown University’s Center on Health Insurance Reforms. “It’s hard to know whether it will make up for the shortfall.”

If they don’t pick a new plan, people who are enrolled in a 2018 marketplace plan may be automatically re-enrolled in their current plan or another one that is similar when the open-enrollment period ends. About a quarter of people who have marketplace plans are reassigned in this way.

Another factor that may be affecting enrollment is tighter federal funding for the health insurance navigators, like Jodi Ray in Tampa, who guide consumers through the complicated process. With fewer experts available to answer questions and help fill out the enrollment forms, consumers may fall through the cracks.

Across the country, funding for navigators dropped from $36 million in 2017 to $10 million this year. In Florida, federal funding for the Covering Florida navigator program was slashed to $1.25 million this year from $4.9 million last year, Ray said. The program was the only one to receive federal funding in the state this year.

The Covering Florida program reduced the number of open-enrollment navigators to 59 this year, a nearly 61 percent drop, Ray said. Navigators this year are available in only half of Florida counties; the organization is offering telephone assistance and virtual visits to people in counties where they can’t offer in-person help.

“It’s all we can do,” Ray said. So far, the group’s navigators have enrolled about half the number of people this year as they had last year.

It’s unclear the extent to which the Trump administration’s efforts to reduce health care costs by expanding access to short-term plans is affecting marketplace plan enrollment.

These plans, originally designed to cover people who expected to be out of an insurance plan for a short time, such as when they change jobs, can be less expensive. Unlike marketplace plans, short-term plans don’t have to provide comprehensive benefits or guarantee coverage for people who have preexisting medical conditions.

The Obama administration limited short-term plans to a three-month term. But in August, the federal government issued a rule that allowed their sale with initial terms of up to a year, and the option of renewal for up to three years.

Ten states either ban short-term plans or restrict them to terms of less than three months, said Sarah Lueck, a senior policy analyst at the Center on Budget and Policy Priorities.

Many people are seemingly not focused on their options this open-enrollment season, however. According to a recent survey, about half of adults under age 65 who were uninsured or who buy their own coverage said they planned to buy a plan for 2019. But only 24 percent of people in that age group said they knew what the deadline was to enroll in health insurance, according to the Kaiser Family Foundation’s November health tracking poll.

Podcast: KHN’s ‘What The Health?’ Is Health Spending The Next Big Political Issue?

The Republican-led Congress was unable to repeal the Affordable Care Act in 2017, but the Trump administration continues to implement elements of the failed GOP bill using executive authority. The latest change would make it easier for states to waive some major parts of the health law, including allowing subsidies for people to buy insurance plans that don’t meet all the law’s requirements.

Meanwhile, in states that are transitioning from Republican governors to Democrats, GOP legislators are using lame-duck sessions to try to scale back executive power and lock in some key health changes, such as work requirements for Medicaid enrollees.

And there is growing evidence that even with health insurance, patients who use significant amounts of medical care are increasingly unable to afford their share.

This week’s panelists for KHN’s “What the Health?” are Julie Rovner of Kaiser Health News, Margot Sanger-Katz of The New York Times, Joanne Kenen of Politico and Rebecca Adams of CQ Roll Call.

Among the takeaways from this week’s podcast:

  • The Trump administration outlined last week what type of waivers it is willing to consider for states’ ACA markets. Options include changes in who gets premium subsidies and how much they receive, and making short-term insurance plans that are not as comprehensive as current marketplace plans eligible for subsidies.
  • Any changes are likely to end up in court, as have most of the revisions that the Trump administration has proposed.
  • In Wisconsin and Michigan, Republican legislatures are seeking to restrict what the new Democratic governors can do to change GOP policies on Medicaid and challenges to the ACA.
  • A recent study has highlighted that health problems can create financial hardships well beyond the illness. For example, loss of income from a debilitating illness can make paying other bills very difficult and sometimes other family members must give up their jobs to be caregivers.

Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read too:

Julie Rovner: NBC News.com’s “FDA Approves Drug for Dogs Scared by Noise,” by Maggie Fox

Margot Sanger-Katz: The Washington Post’s “An Experiment Requiring Work for Food Stamps Is a Trump Administration Model,” by Amy Goldstein

Joanne Kenen: The Atlantic’s “The CRISPR Baby Scandal Gets Worse by the Day,” by Ed Yong

Rebecca Adams: The New York Times’ “Why Hospitals Should Let You Sleep,” by Austin Frakt

Also mentioned in this episode:

The New York Times: “1,495 Americans Describe the Financial Reality of Being Really Sick,” by Margot Sanger Katz

Kaiser Health News: “No Cash, No Heart. Transplant Centers Require Proof of Payment,” by JoNel Aleccia

CBS News: “High Cost Has Many Diabetics Cutting Back on Insulin,” by Serena Gordon

To hear all our podcasts, click here.

And subscribe to What the Health? on iTunesStitcher or Google Play.

Must-Reads Of The Week From Brianna Labuskes

Happy Friday! I don’t know about you, but I have been absolutely riveted by the ethics controversy that has sent the scientific community into a shocked-and-appalled, pearl-clutching frenzy this week. I’ll get to that in a second. First, another too-frequent example of the current pitfalls in our health system: A hospital turned down a woman’s heart transplant request because she lacked a secure source of financing for the drugs necessary for the procedure. The hospital’s suggestion for her? Use crowdfunding to raise the $10,000.

Now here’s what you may have missed as we enter that strange lull between holidays (though there certainly wasn’t a dearth of health news).

New guidelines released by the administration on Thursday, among other things, encourage states to flex their creative muscles on how to spend the subsidy money they get under the health law.

Currently, the subsidies are tied to income, and can be used only for insurance that meets federal standards and is purchased through public marketplaces. But the Centers for Medicare & Medicaid Services wants to lift those restrictions and let states do what they will with the pot of money. That could include: allowing the use of subsidies for short-term “junk insurance” plans; offering subsidies as incentive to woo in younger consumers; setting different income limitations; letting people with employer-based plans set up accounts to use the money, etc., etc.

If states acted on these options, that could steer the marketplace toward the geographical disparity that ran rampant before the health law. But it’s doubtful any state would want to take advantage of this offer in the first place. For one, it would be expensive for states to manage the pot of money. Secondly, even if a state received a waiver for the regulations, court challenges likely would follow. That could be more of a headache than it’s worth.

The Washington Post: New Insurance Guidelines Would Undermine Rules of the Affordable Care Act

Modern Healthcare: CMS Allows States to Get Creative With Federal Exchange Funds Under 1332 Waivers


The lagging numbers for this open-enrollment season are a bit at odds with what experts had seen as a stabilizing, if not quite flourishing, marketplace. While no one is Chicken Little-ing yet (there is still time left to see a boost, and the early weeks of November were busy ones for Americans), health law supporters are concerned that what they see as the administration’s attempts to “sabotage” the Affordable Care Act are coming to fruition.

Politico: Trump May Finally Be Undermining Obamacare

One statistic from the week that experts found “very troubling” was that for the first time in a decade the number of uninsured children rose, despite the improving economy and the low unemployment rate. Rural areas were particularly affected.

Los Angeles Times: Number of Uninsured Children Climbs, Reversing More Than a Decade of Progress, Report Finds


In what is certain to draw fierce pushback from patient advocacy groups and pharma alike, President Donald Trump is expanding Medicare’s negotiating power when certain drug prices rise faster than inflation. The idea has been kicking around for a while as both parties have been trying to come up with the silver bullet for high costs, but the political ramifications are unappetizing. Potentially cutting seniors off from needed drugs — whether it would play out that way or not — has always kept the idea on the back burner.

The New York Times: Trump Moves to Lower Medicare Drug Costs by Relaxing Some Patient Protections

File this under “I’m not sure that’s how it’s supposed to work”: A generic EpiPen is now available. The catch? It’s the exact same price as the one already out there.

The Hill: Generic EpiPen Not Any Cheaper Than Existing Version


FBI background checks were waived for caregivers and mental health workers who were in charge of caring for teens at an immigration detention center in Texas. The revelation ignited outrage, and the Department of Health and Human Services was quick to promise it would fingerprint the employees (officials warned it could take a while, though).

The government also allowed the company who is overseeing the operation of the facility to sidestep mental health requirements — youth shelters generally must have one mental health clinician for every 12 kids, but the contractor was allowed to staff the Texas facility with just one clinician for every 100 children.

The Associated Press: Lawmakers Press for Fingerprinting of Detention Camp Staff

Very quietly, family separations at the border have resumed.

ProPublica: Family Separations Are Still Happening at the Texas Border

Also, Baltimore is suing the Trump administration over its “public charge” policy that lets immigration officials use the acceptance of government aid, such as Medicaid, against those seeking green cards. The lawsuit might be the first of its kind, but it’s doubtful it will be the last.

The Associated Press: Baltimore Sues Trump Administration Over Immigration Policy


It is indicative of just how busy this week was that I haven’t gotten to the (aforementioned) ethics scandal rocking the scientific community yet, but we got here eventually. Chinese scientist He Jiankui dropped a bombshell (unverified and un-peer reviewed) on everyone that he gene-edited human embryos to make designer babies resistant to HIV infections.

This practice crosses an ethical line that many researchers had dug deep, deep, deep in the sand. “Deeply unethical,” “crazy,” “driven by hubris,” were just a few of the reactions from fellow scientists at the shocking news. One consensus that has come out of it, though, seems to be that there’s a crucial need for binding and international guidance on editing human genes. (Oh, and this isn’t over. He says there’s another pregnancy with gene-edited embryos underway.)

Los Angeles Times: Why Geneticists Say It’s Wrong to Edit the DNA of Embryos to Protect Them Against HIV

Stat: He Took a Crash Course in Bioethics, Then Created CRISPR Babies

NPR: Science Summit Denounces Gene-Edited Babies Claim, But Rejects Moratorium

Stat: NIH Director Says There’s Work to Do on Regulating Genome Editing


Medical device policy usually flies a bit under the radar, but it was a hot topic this week. Following a damning report on spinal implants causing severe injury to some patients, the Food and Drug Administration announced that it wants to revamp its (long-criticized and decades-old) approval system.

The Associated Press: FDA Says It Will Overhaul Criticized Medical Device System

And a look at whether the agency’s “first in the world” ambition contributed to a series of high-profile malfunctions.

The Associated Press: At FDA, a New Goal, Then a Push for Speedy Device Reviews


In the miscellaneous file this week:

• The combined suicide and opioid crises are taking a particularly grim toll on the country, sending us into our longest period of generally declining life expectancy since the slice of time that includes a little thing called World War I and the worst flu pandemic in modern history. I’m not going to lie, that’s not a great comparison.

The Associated Press: Suicide, at 50-Year Peak, Pushes Down US Life Expectancy

• A gut-wrenching personal story offers insight into the loved ones left behind in cases of suicides, and how they’re plagued with a forever-unanswerable question of “why”? The entire series is worth a deep read.

USA Today: Suicide: My Mom Took Her Life at The Grand Canyon

• An epidemic of extensive backlog of rape kits languishing on shelves in police departments recently drew a lot of attention. But an even more fundamental and low-profile issue? Those departments that trash them completely before the statute of limitations is up.

CNN: Destroyed: How the Trashing of Rape Kits Failed Victims and Jeopardizes Public Safety

• Johns Hopkins vowed to transform a Florida hospital’s heart surgery unit. Then patients started dying at an alarming rate.

Tampa Bay Times: Heartbroken

• Despite changes in policy, federal prisons are still failing to offer inmates proper mental health care.

The Washington Post/The Marshall Project: Federal Prisons Are Failing Inmates With Mental Health Disorders


As you can tell, it’s a good thing I started drinking coffee (for the first time ever, cue shocked faces) this week! No, I have not been spending my time Googling its health benefits. (OK, I have.) Have a lovely, possibly caffeine-fueled weekend!

Must-Reads Of The Week From Brianna Labuskes

Happy Friday! I don’t know about you, but I have been absolutely riveted by the ethics controversy that has sent the scientific community into a shocked-and-appalled, pearl-clutching frenzy this week. I’ll get to that in a second. First, another too-frequent example of the current pitfalls in our health system: A hospital turned down a woman’s heart transplant request because she lacked a secure source of financing for the drugs necessary for the procedure. The hospital’s suggestion for her? Use crowdfunding to raise the $10,000.

Now here’s what you may have missed as we enter that strange lull between holidays (though there certainly wasn’t a dearth of health news).

New guidelines released by the administration on Thursday, among other things, encourage states to flex their creative muscles on how to spend the subsidy money they get under the health law.

Currently, the subsidies are tied to income, and can be used only for insurance that meets federal standards and is purchased through public marketplaces. But the Centers for Medicare & Medicaid Services wants to lift those restrictions and let states do what they will with the pot of money. That could include: allowing the use of subsidies for short-term “junk insurance” plans; offering subsidies as incentive to woo in younger consumers; setting different income limitations; letting people with employer-based plans set up accounts to use the money, etc., etc.

If states acted on these options, that could steer the marketplace toward the geographical disparity that ran rampant before the health law. But it’s doubtful any state would want to take advantage of this offer in the first place. For one, it would be expensive for states to manage the pot of money. Secondly, even if a state received a waiver for the regulations, court challenges likely would follow. That could be more of a headache than it’s worth.

The Washington Post: New Insurance Guidelines Would Undermine Rules of the Affordable Care Act

Modern Healthcare: CMS Allows States to Get Creative With Federal Exchange Funds Under 1332 Waivers


The lagging numbers for this open-enrollment season are a bit at odds with what experts had seen as a stabilizing, if not quite flourishing, marketplace. While no one is Chicken Little-ing yet (there is still time left to see a boost, and the early weeks of November were busy ones for Americans), health law supporters are concerned that what they see as the administration’s attempts to “sabotage” the Affordable Care Act are coming to fruition.

Politico: Trump May Finally Be Undermining Obamacare

One statistic from the week that experts found “very troubling” was that for the first time in a decade the number of uninsured children rose, despite the improving economy and the low unemployment rate. Rural areas were particularly affected.

Los Angeles Times: Number of Uninsured Children Climbs, Reversing More Than a Decade of Progress, Report Finds


In what is certain to draw fierce pushback from patient advocacy groups and pharma alike, President Donald Trump is expanding Medicare’s negotiating power when certain drug prices rise faster than inflation. The idea has been kicking around for a while as both parties have been trying to come up with the silver bullet for high costs, but the political ramifications are unappetizing. Potentially cutting seniors off from needed drugs — whether it would play out that way or not — has always kept the idea on the back burner.

The New York Times: Trump Moves to Lower Medicare Drug Costs by Relaxing Some Patient Protections

File this under “I’m not sure that’s how it’s supposed to work”: A generic EpiPen is now available. The catch? It’s the exact same price as the one already out there.

The Hill: Generic EpiPen Not Any Cheaper Than Existing Version


FBI background checks were waived for caregivers and mental health workers who were in charge of caring for teens at an immigration detention center in Texas. The revelation ignited outrage, and the Department of Health and Human Services was quick to promise it would fingerprint the employees (officials warned it could take a while, though).

The government also allowed the company who is overseeing the operation of the facility to sidestep mental health requirements — youth shelters generally must have one mental health clinician for every 12 kids, but the contractor was allowed to staff the Texas facility with just one clinician for every 100 children.

The Associated Press: Lawmakers Press for Fingerprinting of Detention Camp Staff

Very quietly, family separations at the border have resumed.

ProPublica: Family Separations Are Still Happening at the Texas Border

Also, Baltimore is suing the Trump administration over its “public charge” policy that lets immigration officials use the acceptance of government aid, such as Medicaid, against those seeking green cards. The lawsuit might be the first of its kind, but it’s doubtful it will be the last.

The Associated Press: Baltimore Sues Trump Administration Over Immigration Policy


It is indicative of just how busy this week was that I haven’t gotten to the (aforementioned) ethics scandal rocking the scientific community yet, but we got here eventually. Chinese scientist He Jiankui dropped a bombshell (unverified and un-peer reviewed) on everyone that he gene-edited human embryos to make designer babies resistant to HIV infections.

This practice crosses an ethical line that many researchers had dug deep, deep, deep in the sand. “Deeply unethical,” “crazy,” “driven by hubris,” were just a few of the reactions from fellow scientists at the shocking news. One consensus that has come out of it, though, seems to be that there’s a crucial need for binding and international guidance on editing human genes. (Oh, and this isn’t over. He says there’s another pregnancy with gene-edited embryos underway.)

Los Angeles Times: Why Geneticists Say It’s Wrong to Edit the DNA of Embryos to Protect Them Against HIV

Stat: He Took a Crash Course in Bioethics, Then Created CRISPR Babies

NPR: Science Summit Denounces Gene-Edited Babies Claim, But Rejects Moratorium

Stat: NIH Director Says There’s Work to Do on Regulating Genome Editing


Medical device policy usually flies a bit under the radar, but it was a hot topic this week. Following a damning report on spinal implants causing severe injury to some patients, the Food and Drug Administration announced that it wants to revamp its (long-criticized and decades-old) approval system.

The Associated Press: FDA Says It Will Overhaul Criticized Medical Device System

And a look at whether the agency’s “first in the world” ambition contributed to a series of high-profile malfunctions.

The Associated Press: At FDA, a New Goal, Then a Push for Speedy Device Reviews


In the miscellaneous file this week:

• The combined suicide and opioid crises are taking a particularly grim toll on the country, sending us into our longest period of generally declining life expectancy since the slice of time that includes a little thing called World War I and the worst flu pandemic in modern history. I’m not going to lie, that’s not a great comparison.

The Associated Press: Suicide, at 50-Year Peak, Pushes Down US Life Expectancy

• A gut-wrenching personal story offers insight into the loved ones left behind in cases of suicides, and how they’re plagued with a forever-unanswerable question of “why”? The entire series is worth a deep read.

USA Today: Suicide: My Mom Took Her Life at The Grand Canyon

• An epidemic of extensive backlog of rape kits languishing on shelves in police departments recently drew a lot of attention. But an even more fundamental and low-profile issue? Those departments that trash them completely before the statute of limitations is up.

CNN: Destroyed: How the Trashing of Rape Kits Failed Victims and Jeopardizes Public Safety

• Johns Hopkins vowed to transform a Florida hospital’s heart surgery unit. Then patients started dying at an alarming rate.

Tampa Bay Times: Heartbroken

• Despite changes in policy, federal prisons are still failing to offer inmates proper mental health care.

The Washington Post/The Marshall Project: Federal Prisons Are Failing Inmates With Mental Health Disorders


As you can tell, it’s a good thing I started drinking coffee (for the first time ever, cue shocked faces) this week! No, I have not been spending my time Googling its health benefits. (OK, I have.) Have a lovely, possibly caffeine-fueled weekend!

Short On Federal Funding, Obamacare Enrollment Navigators Switch Tactics

Enrollment is down sharply on the federal health insurance marketplace this fall, and the consumer assistance groups that help with sign-ups think they know why.

They don’t have the staff to help as many customers as before because the Trump administration slashed funding. The federal government is spending $10 million this year on navigators who help individuals enroll in coverage. The government spent $36 million in 2017 and $63 million in 2016.

“We don’t have the people to provide the enrollment assistance nor to do the outreach and marketing to let people know what’s happening,” said Jodi Ray at the University of South Florida, who has overseen Florida’s largest navigator program since 2014.

Ray’s program received $1.2 million in federal funding this year, down from $5 million a year ago. Florida leads the nation in enrollment in the Affordable Care Act marketplace plans.

With less money, Ray can afford to pay only 59 navigators across the state this year, down from 152 a year ago. With fewer navigators, much of the group’s counseling is done by phone instead of in person. That complicates their job, she said, because it is much easier to talk with and show marketplace customers in person when looking at dozens of health plans with different costs and benefits.

Open enrollment in the Obamacare plans began Nov. 1 and will run until Dec. 15 for the 39 states covered by the federal exchange, healthcare.gov. The other exchanges — run by states — typically extend until the end of December or into January.

Obamacare plans are for people without workplace or government coverage.

Nationwide, navigator groups are scrambling to make up for the loss of federal funding to ensure they can help people make sense of their health insurance options.

  • In South Carolina, the Palmetto Project has transformed into the state’s first nonprofit insurance agency. Several of its former federally funded navigators are now licensed insurance agents. In their new role, they get paid a commission on their sales and don’t have to follow Trump administration rules that encourage navigators to talk to customers about short-term plans with limited benefits. The agents can also help customers enroll in Medicaid, Medicare and off-exchange plans.
  • The Community Council of Greater Dallas, which was funded last year to help with enrollment in 56 counties, has raised money from private donors to continue serving seven counties around Dallas. But it has 25 fewer navigators, so consumers seeking help must wait three days on average, compared with less than a day last year. Across Texas, 211 of 254 counties have no federally paid navigators.
  • In Wisconsin, the organization Covering Wisconsin has raised millions of dollars from cities, counties and local United Way chapters, as well as the state Medicaid agency, to make up for the federal cuts. Even still, it will be able to provide in-person assistance in only eight counties around Milwaukee and Madison. Twenty other counties are served by telephone.
  • The Kansas Association for the Medically Underserved is relying totally on volunteers to help consumers with in-person and telephone assistance. In the past year, the association was able to use government funding to pay about 20 navigators.

Nationally, nearly 800 counties served by the federal marketplace will not have any federally funded navigators this fall — up from 127 counties in 2016, according to the Kaiser Family Foundation. (KHN is an editorially independent program of the foundation.)

Federal officials said they were not providing funds for navigators in Iowa, Montana or New Hampshire because no organizations applied in those states.

Nearly 12 million people across the country — including nearly 9 million on the federal exchange — enrolled in Obamacare plans for 2018.

At the halfway point in the six-week enrollment period, 2.4 million people chose a plan for the 2019 coverage year on healthcare.gov, the federal health insurance exchange, according to data released Wednesday by the federal Centers for Medicare & Medicaid Services. That compares with nearly 2.8 million consumers who selected their coverage through the exchange during the first 25 days last year.

Among states with the largest enrollment drops: Pennsylvania (down 25 percent from last year), Missouri (down 25 percent) and Ohio (down 20 percent).

The annual enrollment tally is being closely followed in part because 2019 marks the first year since the marketplace plans began in 2014 that Americans won’t be fined for failing to have coverage.

But consumer experts think the lack of navigator funding could end up having a bigger impact on enrollment. Caroline Gómez-Tom, navigator program manager of Covering Wisconsin, said the end of the so-called individual mandate penalty has been a “non-issue” among people seeking coverage.

“Some folks mention it, but at the end of the day they still walk away with health coverage,” she said. “The ability to have coverage at affordable prices outweighs the penalty being gone because people still see health care insurance as important to have.”

Consumers generally have a greater choice of plans for 2019 as more companies enter the individual market and existing plans expand service areas. Plus, premiums are dropping in some areas, and where they are rising the rate of increase is among the lowest in several years.

Katrina McGivern, director of policy and public affairs for the Kansas Association for the Medically Underserved, said people in rural areas of the state will have the most difficulty getting help as a result of funding cuts.

After five years of experience, she said, she is hopeful that people are figuring out how to do it on their own. Still, she added, there are always “people who need assistance to get through it.”

Is Trump Pushing Health Insurance Innovation Or An ACA Rollback?

On his first day in office, as part of his mission to dismantle the Affordable Care Act, President Donald Trump signed an order promising to give states flexibility “to create a more free and open healthcare market.”

The administration on Thursday released an official set of examples to help states flex these powers.

It is intended to roll back key elements of Obama-era requirements, which were designed to promote enrollment in ACA plans that cover a broad range of medical needs and meet uniform national standards.

Seema Verma, the Centers for Medicare & Medicaid Services administrator, said those strict rules were seen by many as burdensome, and “virtually impossible” for states to meet.

Instead, the Trump administration wants states to innovate in ways that could produce more lower-cost options, even if those alternatives do not provide the same level of financial or medical coverage as an ACA plan.

“I’m confident states will come up with ideas that will work better,” said Verma.

Still, coupled with other ongoing efforts by the Trump administration to gut Obamacare, policy experts predict the ideas would further foster a parallel market of cheaper, less robust coverage that could draw younger or healthier consumers, but drive up premiums for those who remain in ACA market plans.

“Invariably, the coverage is going to be more expensive for people who really need comprehensive coverage,” said Timothy Jost, a retired Washington and Lee University law professor who follows the ACA closely.

One of the biggest changes signaled by the administration involves allowing states to revamp how federal subsidies are used. Currently, they are strictly targeted to lower-income Americans and are seen as key to bolstering enrollment in marketplace plans.

The Trump guidance would give states wider latitude to expand or narrow the income range eligible for subsidies, target them toward younger people or allow them to be used for less costly but skimpier types of insurance.

This would “potentially upend the subsidy structure,” said Sabrina Corlette, research professor at Georgetown University’s Health Policy Institute.

Another example would, for the first time, make federal subsidy money available to people who get job-based insurance, countering Obama-era rules that generally prohibited that. It would let states use federal dollars to fund accounts consumers could use to buy insurance or pay other health costs, such as deductibles or copayments. Employers or consumers could also add additional funds to these accounts.

Still, managing those accounts would be a large administrative expense for a state to oversee, said Corlette. “I don’t understand why a state would want to set it up,” she added.

Supporters say the examples unveiled Thursday would give consumers more control over how they choose to spend their health care dollars and the types of coverage they want to buy. They say it might also improve the markets, which are seeing declining enrollment as premiums rise.

“If states can provide larger subsidies to younger individuals to attract them to enroll, that will improve the market overall,” said Christopher Condeluci, a Washington, D.C., attorney who specializes in employee benefits and has served as the tax and benefits counsel to the U.S. Senate Finance Committee.

However, if many states follow the administration’s lead, critics say, it would bring back the days when insurance rules varied widely state by state. Consumers could end up buying skimpier plans that leave them vulnerable to high, unexpected medical bills.

While not prescriptive, the examples are designed to encourage states to innovate and apply for permission to offer more choices for consumers, so long as the proposals don’t cost taxpayers more and don’t reduce access to ACA plans, said Verma.

State proposals would still have to be affordable, comprehensive and not raise the federal deficit, she said. And CMS would pay particular attention to potential effects on low-income Americans, she added.

Reshaping The Individual Market

The administration’s examples focus on states’ health marketplaces, where insurance plans are designed for individuals who don’t get job-based coverage and small businesses. An estimated 14 million people buy their own coverage through those markets or through brokers.

Premiums in those markets have risen substantially since the law took effect in 2014, for a variety of reasons, including lower-than-expected enrollment by healthy people and actions taken by Congress and the Trump administration that removed the tax penalty for failing to have coverage, eliminated some payments to insurers and loosened restrictions on alternative types of insurance plans.

The administration’s examples add a new twist to a provision of the ACA, which gave states the option of seeking a federal waiver to develop alternative marketplace proposals.

To get one under Obamacare rules, however, states have to meet four “guardrails” established in 2015. These require states to ensure their proposals would provide equally comprehensive and affordable coverage, not result in fewer people enrolling or increased costs for taxpayers.

The examples, tapped by the administration as “waiver concepts,” build on the Trump administration guidance issued in late October to loosen those guardrails. That guidance, effective in 2020, says states have to provide access to affordable and comprehensive coverage, but will not be held to a strict tally of how many people actually enroll. So long as a state could show that equal numbers of people were buying some kind of coverage — either comprehensive ACA plans or less expensive but skimpier plans — it could pass the test.

That October announcement, and Thursday’s concepts, drew immediate criticism from ACA supporters, who said it encourages the use of subsidies to buy short-term plans, which aren’t as comprehensive as ACA coverage and can bar people with preexisting conditions.

Congressional Democrats sent a letter to top administration officials saying the process by which the changes are being made — meaning they are not following a formal rule-making process — are illegal.

“We believe this sub-regulatory guidance exceeds the Secretaries’ statutory authority,” wrote Ways & Means ranking member Richard Neal (D-Mass.) and Energy and Commerce ranking member Frank Pallone Jr. (D-N.J.). “It appears to be part of the Administration’s ideologically motivated efforts to sabotage the ACA.”

The Brookings Institution and other experts have raised similar questions and predicted a legal challenge.

“As soon as any state proceeds to go somewhere with this, there will be legal challenges,” said Jost, the law professor.

Verma pushed back against this warning, noting that the Obama administration also issued its guardrails as guidance, not a formal rule.

And, just as when the administration released its earlier guidance in October, Verma anticipated that critics would say the ideas would adversely affect people with preexisting medical conditions.

Those critics argue that anything that draws younger and healthier people out of the market will drive up costs for those who remain in ACA plans, including those with medical conditions who might be barred from buying an alternative policy, such as a short-term plan.

But Verma said that “nothing in this guidance would take away protections from people with preexisting conditions.”

Podcast: KHN’s ‘What The Health?’ Reading The Tea Leaves In Blue Wave’s Wake

This week, “What the Health?” panelists discuss, among other things, how the House Democrats’ leadership battle could affect the congressional health policy agenda.

The panelists are Mary Agnes Carey of Kaiser Health News, Margot Sanger-Katz of The New York Times, Alice Ollstein of Politico and Anna Edney of Bloomberg News.

As the post-election dust settles on Capitol Hill, the Democrats — soon to be in control of the House of Representatives — have begun the process of choosing their leadership team. How this shakes out will have a lot to do with how health policy agenda takes shape in the lower chamber.

House Democrats nominated Rep. Nancy Pelosi (D-Calif.) to retake the speaker’s gavel, but she still needs to win over more of her colleagues to secure the speaker post in January.

But all the action this week wasn’t focused on Congress. Food and Drug Administration Commissioner Scott Gottlieb unveiled a proposed overhaul of the FDA’s decades-old medical device approval process, and the Trump administration announced proposals it said would reduce Medicare prescription drug costs. Critics fear those changes could mean that some people with chronic diseases like AIDS or cancer might not have access to the drugs they need.

Among the takeaways from this week’s podcast:

  • House Democrats nominated Rep. Nancy Pelosi (D-Calif.) to retake the speaker’s gavel this week along with the rest of its leadership slate, Reps. Steny Hoyer of Maryland and Jim Clyburn of South Carolina. This is only the first step, though. The leadership positions will not be filled officially until January, when they are voted on by the full House. Although Pelosi is still wrangling for the support needed to earn her the required 218 votes, most insiders expect the Democrat’s leadership team to look much as it did the last time Democrats ruled the House chamber in 2010, when the Affordable Care Act became law. That means the House will likely be laser-focused on the necessary steps to protect the ACA. There may also be hearings on single-payer health insurance — a concept that is increasingly gaining interest and support within the caucus, and especially among some of its newest members.
  • In the background, the Texas lawsuit that could overturn the ACA’s protections for people with preexisting conditions is still pending. That decision could come any day. Keep in mind, though, that whatever the court rules, it is likely to be appealed immediately and move up the legal ladder. And, in the interim, House Democrats may still move forward with legislation to strengthen those ACA safeguards. Such a measure could get some GOP support because many Republicans seeking re-election this year said they wanted to ensure that patients with preexisting medical conditions would not lose coverage.
  • The FDA unveiled a proposed overhaul of its decades-old medical device approval system. Among its provisions, the plan includes steps to ensure that new medical devices reflect current safety and effectiveness features. Critics of the current system say it has failed to detect problems with some implants — like hip replacements that failed prematurely or surgical mesh that has been linked to pain and bleeding. The changes, if approved, could take years to implement and some might require congressional approval.
  • The Trump administration proposed a series of changes to reduce the number of prescription drugs that all Medicare drug plans must cover. The proposal focuses on drugs in six “protected classes” and involves medications such as antidepressants, antipsychotic medicines, cancer drugs and antiretrovirals to treat HIV/AIDS. Administration officials have said the proposal could cut costs for Medicare, but patient advocacy groups say it could reduce patients’ access for much-needed treatments. The proposed changes would not occur until 2020, and Congress could intervene to stop them.

Also this week, Julie Rovner interviews KHN senior correspondent Jay Hancock, who investigated and wrote the latest “Bill of the Month” feature for Kaiser Health News and NPR. It’s about a single mother from Ohio who received a wrongful bill for her multiple sclerosis treatment. You can read the story here.

If you have a medical bill you would like NPR and KHN to investigate, you can submit it here.

Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read too:

Mary Agnes Carey: The New York Times’ “This City’s Overdose Deaths Have Plunged. Can Others Learn From It?” by Abby Goodnough

Margot Sanger-Katz: NPR’s “Rethinking Bed Rest for Pregnancy,” by Alison Kodjak

Anna Edney: The Washington Post’s “Overdoses, Bedsores, Broken Bones: What Happened When a Private-Equity Firm Sought to Care for Society’s Most Vulnerable,” by Peter Whoriskey and Dan Keating

Alice Ollstein: Wired.com’s “The Science Is Clear: Dirty Farm Water Is Making Us Sick,” by Elizabeth Shogren and Susie Neilson

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