Diverse Group Of Health Care Stakeholders Float Legislative Agenda

Inside Health Policy

July 27, 2021 9:09 am

A diverse group of 18 health care stakeholders including beneficiary advocates, insurers and businesses are pushing a legislative agenda that includes expanding and strengthening coverage in Medicaid/CHIP and the exchanges.

Many of the policies they support are expected to be in the budget reconciliation package being put together by the Democrats, but others could be included in subsequent vehicles.

The stakeholders offer dozens of ideas in their seven-page memo but point to four policy priorities: strengthen funding and expand eligibility for Medicaid/CHIP; improve the affordability of plans sold on the marketplaces; qualify all legal immigrants into public health programs without a waiting period; and enroll people who are eligible but not enrolled in low-cost coverage.

The policies are backed by Families USA, Association for Community Affiliated Plans (ACAP), Small Business Majority, National Immigration Law Center (NILC), AHIP, American Academy of Pediatrics, American College of Physicians, Blue Cross Blue Shield Association, Catholic Health Association of the United States, Federation of American Hospitals, NAACP, National Birth Equity Collaborative, National Council of Urban Indian Health, National Health Council, National Partnership for Women & Families, Third Way, UnidosUS and Young Invincibles.

“The deadliest pandemic in more than a century and sharpest economic downturn since the Great Depression have made it crystal clear that affordable, high-quality coverage is critical to the entire nation’s well-being, not just individual families,” Frederick Isasi, executive director of Families USA, said when unveiling the policy agenda on July 12.

“If our elected leaders don’t act, we will have wasted the most devastating lesson of our lifetimes. Passing these commonsense proposals, which enjoy broad support from across the political spectrum, would be a strong statement that America is going to come back stronger than ever,” he said.

“These proposals provide concrete actions lawmakers can take to address long-standing gaps in coverage brought into sharp relief by the COVID-19 pandemic,” adds Margaret A. Murray, CEO of ACAP.

The lobby especially supports policies that, like continuous eligibility in Medicaid, would prevent consumers from churning between health programs, which threatens health care outcomes and creates bureaucratic hurdles.

“All of us, no matter how much money we have, what we look like or where we were born, should have access to quality and affordable health care, says Avideh Moussavian, director of federal advocacy at the NILC. “But for too long, health care programs that keep communities healthy have excluded immigrants through eligibility restrictions, outreach failures, and a lack of affordability.”

David Chase, vice president of outreach for the Small Business Majority, says that millions of small businesses, especially those in underserved communities, were disproportionately impacted by the pandemic and “helplessly as revenues needed to pay health premiums were wiped out overnight.”

“Congress now has an opportunity and obligation to enact substantive policies that will make high-quality health care coverage affordable for small businesses as they try to rebuild from the devastation of the pandemic. The many and diverse organizations that collaborated on this project is evidence that common-sense solutions can be reached across a broad spectrum of missions,” he said

“We call on lawmakers to review the menu of policy options outlined and consider including some or all in their next legislative package,” Chase added.

Democrats have already said that they plan to include several of the priorities in the reconciliation package, including closing the Medicaid gap and permanently extending the increased tax credits and help for higher-income families in the American Rescue Plan.

Lawmakers also want to expand funding for home- and community-based services, and add dental, vision and hearing benefits to Medicare.

Those health care policies could make up close to a third of the $3.5 trillion that the Senate Budget Committee Democrats tentatively agreed upon for the reconciliation package, but that top-line has not yet been approved by the full caucus and is expected to come down, which means the heath policies may need to be trimmed.

Isasi says the haircut phase is because the pay-for are still unsettled, and much will depend on the whether Congress can pass meaningful drug pricing reforms. The drug-pricing pay-for could be as much as $450 billion under the House drug pricing bill or less than $100 billion depending on what Senate Finance Committee Chair Ron Wyden (D-OR) includes in the alternative bill he is drafting.

There’s a lot of excitement on the new oral benefit, and a well-identified need, Isasi says. But there’s no way to answer whether the new benefit — which costs an estimated $230 billion — can make the final package until they do the math. Inside Health Policyrecently reported that the administration could administratively expand medically necessary dental coverage, which could lower the cost of what Congress might add on dental benefits. Isasi expects to see an announcement from CMS as early as August.

Families strongly supports all of the health policies slated for the package, and Isasi says the current experience with the Delta variant of COVID-19 underscores the need to act quickly.

Policy proposals:

Medicaid and CHIP. For Medicaid, the group says the federal medical assistance percentage (FMAP) should be given the flexibility to automatically increase during downturns and include maintenance of effort policies. This would make Medicaid a powerful took to combat recession and while protecting families and state budgets, the stakeholders say.

The group also urges Congress to make CHIP funding permanent; lift funding caps and establish FMAPs for Puerto Rico and other territories that are no less generous than what states receive and provide 100% FMAP for Urban Indian Health Programs. Congress should enact policies that prevent coverage disruptions in Medicaid and CHIP by providing — and sufficiently funding – five-year continuous enrollment for young children, 12-month eligibility for children and adults, 12-month continuous eligibility for postpartum care to address high maternal mortally rates and higher FMAP.

They also call for automatically enrolling newborns in Medicaid if there’s no other proof of coverage. “This includes automatic enrollment in the mother’s Medicaid plan unless the parent or parents choose a different plan for their child,” the proposal says. Also, Medicaid should cover the justice-involved populations 30-days prior to release to prevent any disruptions in care.

The stakeholders also support policies to close the Medicaid gap, saying Congress should provide Medicaid-level coverage for the 2 million uninsured people that live below poverty in states that have refused to expand their Medicaid programs. This policy should be coupled with significant incentives for states to retain or further expand the program, according to the proposal.

 Equity-focused Medicaid improvements like language access, telehealth services, and perinatal care should also be on the agenda. Medicaid should also be required to cover adult dental services – including for those dually eligible for Medicare.

Regarding lawfully present immigrants, the groups call for removing any statuary restrictions – including waiting periods – that block that population from enrolling in public health programs.

A recent Health Affairs article found that non-citizen children face more harm than their siblings that are citizens, including delays in needed care largely due to the lack of insurance. The authors suggest the United States “reexamine policies that exclude noncitizen children from public health insurance programs,” according to an abstract.

ACA reforms. To improve affordability of marketplace plans, the stakeholders call for the permanently extending the increased tax credits in the American Rescue Plan. They also say the APTC structure should be tweaked to offer more support for younger adults, which the Blue Cross Blue Shield Association (BCBSA) has been pushing for years. The policy should not result in increased premiums for older adults, the proposal says.

The stakeholders also want the ACA’s cost-sharing reductions funded and extended to people earning up to 400% FPL, and say the premium tax credits should be linked to the gold level with an 80% actuarial value rather than silver-level plan with 70% AV.

Both policies, as well as permanently expanding the ARP tax credits, are included in legislation sponsored by Sen. Jean Shaheen (D-NH), the Improving Health Care Affordability Act (S. 499). Shaheen’s office said recently that driving down deductibles and cost-sharing is critical to ensuring consumers can use their coverage without facing high out-of- pocket costs.

“These policies enjoy support from across the ideological spectrum within the Democratic caucus and need to be a part of the discussion when the Senate considers legislation to bring down health care costs,” Shaheen’s office said in a recent email.

 Stakeholders also call for a fix of the “family glitch,” which currently blocks about 5 million dependents from accessing the ACA’s premium tax credits if a worker is offered affordable self-only coverage even if the offer for family coverage is unaffordable. The fix should be structured so that is does not expose employers to additional liability, the groups say.

Congress has yet to include a fix to the glitch in any recent proposals, but sources say the administration is working on a regulatory solution that would allow family members to get subsidies even if the employee is enrolled in employer coverage.

Tax credits should be available for student health plans that fully comply with the ACA, which would help low- and moderate-income student access affordable coverage, the stakeholders say.

Enrollment and eligibility reforms across programs. Finally, the stakeholders call for mechanisms that would help ensure all eligible beneficiaries are enrolled in coverage. The groups say Congress should make enrollment as automatic as possible by allowing consumers to consent on their tax forms to sharing their information with the relevant insurance exchange to determine coverage eligibility. Eligible consumers could also be enrolled into a $0 premium coverage plan, CHIP or Medicaid if they don’t choose a different plan or opt out.

They also suggest basing eligibility for public programs on prior year tax forms, creating pathways for people on unemployment to access insurance assistance programs and making permanent Express Lane Eligibility, which streamlines enrollment in other benefit programs, like SNAP, with Medicaid.