On his first day in power, as part of his dismantling of the Affordable Care Act, President Trump signed an order promising to give states the flexibility to "create a freer health care market." and open ".
The administration released Thursday a series of official examples designed to help states relax these powers.
It is planned to remove key elements of the Obama era requirements, designed to promote enrollment in ACA regimes covering a wide range of medical needs and meeting uniform national standards.
Seema Verma, administrator of Medicare Centers and Medicaid Services, said the strict rules were considered by many to be "heavy and" virtually impossible "for states.
The Trump administration rather wants states to innovate in order to produce more options at lower cost, even if these solutions do not offer the same level of financial or medical coverage as a plan. d & # 39; ACA.
"I am confident that states will come up with ideas that will work better," Verma said.
Nevertheless, coupled with other ongoing Trump administration efforts to wipe out Obamacare, policy experts are predicting that the ideas would favor a parallel market offering cheaper and less robust coverage likely to attract younger or younger consumers. in better health, but to increase the premiums for those who stay at ACA. market plans.
"Invariably, the blanket will cost more to people who really need it," said Timothy Jost, a retired law professor at the University of Washington and Lee, who closely follows the ACA.
States could change grant recipients
One of the most important changes reported by the administration is to allow states to reorganize the use of federal grants. At present, these subsidies are strictly targeted at low-income Americans and are seen as an essential element to enhance participation in market programs.
Trump's guidelines would give states more flexibility to expand or reduce subsidy-eligible income ranges, target them to younger people or allow them to be used for cheaper but smaller types of insurance.
This could "disrupt the grant structure," said Sabrina Corlette, a research professor at the Health Policy Institute at Georgetown University.
Another example would, for the first time, make federal grants available to people who benefit from employment-based insurance, which would defeat the rules of employment. 39, the Obama era, which generally forbade this. States could use federal dollars to finance accounts that consumers could use to purchase insurance or pay other health costs, such as deductibles or co-payments. Employers or consumers could also add additional funds to these accounts.
Nevertheless, the management of these accounts would represent an important administrative expense to monitor for a state, said Corlette. "I do not understand why a state would like to install it," she added.
Proponents of Trump's plan say the examples unveiled Thursday would give consumers more control over how they choose to spend their money on health care and the type of coverage they want to buy. They say it could also improve markets, which are seeing their listings decrease as their premiums go up.
"If states can give larger subsidies to younger people to get them to sign up, it will improve the market as a whole," said Christopher Condeluci, a Washington-based lawyer who specializes in benefits and has served of the US Senate Finance Committee.
However, if many states comply with the administration, critics say, this would reduce the time when insurance rules varied considerably from state to state. Consumers could end up buying tiny packages that expose them to high and unexpected medical bills.
Although they are not normative, the examples are designed to encourage states to innovate and ask permission to offer more choice to consumers, as long as the proposals do not cost more to taxpayers and do not reduce access to ACA plans, Verma said.
States' proposals will always have to be affordable, comprehensive and not increase the federal deficit, she said. And CMS will pay special attention to the potential effects on low-income Americans, she added.
Reshape the individual insurance market
Examples of the administration focus on the state health markets, where insurance plans are designed for small businesses and for people who do not benefit from coverage based on the # 39; employment. It is estimated that 14 million people buy their own cover through these markets or brokers.
Premiums in these markets have increased significantly since the law came into force in 2014 for a variety of reasons. Among these reasons, there is a lower registration rate than expected in healthy people; the measures taken by Congress and the Trump administration that removed the penalty tax for non-coverage; and other initiatives that have eliminated some payments to insurers and relaxed restrictions on other types of insurance plans.
The examples of the administration add a new twist to a provision of the ACA that gave states the opportunity to seek a federal waiver to develop alternative market proposals.
To obtain a waiver under the Obamacare rules, however, States must comply with four "security barriers" established in 2015. These require States to ensure that their proposals provide equally complete and comprehensive coverage. affordable; would result in no less registrations; and would not increase costs for taxpayers.
The examples described on Thursday – presented as "waiver concepts" by the Trump administration – support the directives of the administration issued in late October to loosen these guardrails.
This October directive, which will come into effect in 2020, states that states must provide access to comprehensive and affordable coverage, but will not be required to strictly count the number of people actually registered. As long as a state can show that an equal number of people are buying some sort of coverage – complete ACA plans or cheaper but more modest plans – the state's approach can pass the test.
This October announcement and Thursday's concepts sparked immediate criticism from ACA supporters, who said it encourages the use of subsidies to buy short-term plans, which are less comprehensive that ACA coverage and can prevent people with pre-existing diseases.
Congressional Democrats sent a letter this week to senior administration officials, in which they said the amendment process is illegal because the administration does not follow a formal process of establishment. rules.
"We believe these subregulatory guidelines go beyond the statutory authority of secretaries," said Richard Neal, a member of the Ways & Means ranking, and Frank Pallone Jr., a member of the Energy and Commerce ranking, D-N.J. "It seems to be part of the ideological efforts of the administration to sabotage the ACA."
The Brookings Institution and other experts have raised similar issues and predicted a court challenge.
"As soon as any state proceeds to go somewhere with that, there will be legal challenges," said Jost.
Verma rebuffed this warning, pointing out that the Obama administration had also released its "security slides" as an indication, and not as a formal rule.
Verma said she was expecting critics to say that the ideas would negatively affect people with pre-existing medical conditions.
These critics argue that anything that attracts younger, healthier people to the market will drive up costs for those who stay in the ACA plans – including those with health problems, to whom it could be banned from buying another policy, such as a short term plan. .
But Verma said that "nothing in this guide will prevent people with pre-existing conditions from being protected."
Kaiser Health News, a non-profit information service covering health issues, is an independent editorial program of the Kaiser Family Foundation which is not affiliated with Kaiser Permanente.