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The Health 202: Trump administration offers states four ways to circumvent Obamacare rules


The Trump administration is providing states with a roadmap for how they can sidestep parts of the Affordable Care Act in the name of giving more power back to the states. But critics fear the move will undermine key consumer protections established by the 2010 health-care law.

The Centers for Medicare and Medicaid Services yesterday released four recommendations for how states could obtain waivers from ACA rules from the federal government, expanding on guidance released last month that aimed to give states more flexibility in forging their own path on health care.

Health and Human Services Secretary Alex Azar praised the move, while Democrats pounced on it. And health-care experts say the templates allow states, following a failed Republican bid to repeal and replace the ACA, to circumvent some of the law’s rules on their own.

In the guidance issued last month, the administration took a major step to change the nature of state marketplaces by stating that federal subsidies would no longer be limited to ACA plans. As my Washington Post colleague Amy Goldstein reports: “States could allow the subsidies to be used for health plans the administration has been promoting outside the ACA marketplaces that are less expensive because they provide skimpier benefits and fewer consumer protections. In an even more dramatic change, states could let residents with employer-based coverage set up accounts in which they mingle the federal subsidies with health-care funds from their job or personal tax-deferred savings funds to use for premiums or other medical expenses.”

CMS elaborated on the possible waiver yesterday, along with three other potential ways state officials could take advantage of the new flexibility. If granted waivers, states could design their own state-administered subsidy programs, determine what different types of health insurance plans are eligible for subsidies and implement risk stabilization programs.

Sarah Lueck, a senior policy analyst at the Center on Budget and Policy Priorities, told me the concepts were reminiscent of some ideas that emerged during the repeal-and-replace debate last year. She said they would allow states to “pursue policies that could reduce subsidies available for vulnerable populations, offer inadequate coverage options or leave people with unaffordable coverage.”

“Potentially, what this guidance and concept ideas are saying is: ‘States, you can try to do what was rejected in Congress,' ” Lueck added. “But whether it’s the bad ideas from the repeal debate or returning to the pre-ACA-style market, it’s not going to fare as well for people if they have a preexisting condition, if they’re older, low-income — those concerns are very real.”

In a speech before the conservative American Legislative Exchange Council, CMS Administrator Seema Verma delivered a rebuke of the ACA in her explanation for why the agency wants to give more freedom to the states.

“Seeing the problems the ACA created, and seeing the lack of federal action to address these problems, should be proof enough for why it was such a mistake to federalize so much of health-care policy under the ACA,” she said.

The agency is even moving to rename the state waivers to push its point. As Goldstein reports: “In urging states to consider the changes, CMS is renaming a provision of the law, known as 1332, which until now has mainly been used to give states permission to create programs to ease the burden on insurers of high-cost customers. CMS is switching the name to ‘State Relief and Empowerment Waivers,’ emphasizing the administration’s desire to hand off health-care policies to states.”

In a statement Thursday, Azar praised the recommendations. “The Trump administration is committed to empowering states to think creatively about how to secure quality, affordable healthcare choices for their citizens,” he said. “The specific examples laid out today show how state governments can work with HHS to create more choices and greater flexibility in their health insurance markets, helping to bring down costs and expand access to care.”

But top Democrats raised questions about the legality of the guidance and expressed concern about how such moves could undermine key Obamacare elements.

For her part, Sen. Patty Murray (D-Wash) called the new possible waives “nothing more than a how-to guide for health care sabotage.”

“The Trump administration is brazenly warping a tool meant to help states innovate and lower prices so it can further gut protections for people with pre-existing conditions and drive up health care costs,” the top Democrat on the Senate Health, Education, Labor and Pensions Committee said in a statement. “Congress created these waivers and included guardrails to allow for innovation while making sure people could get high-quality, affordable coverage—however the Trump Administration’s guidance takes us in the opposite direction.”

In a letter to Verma and other Cabinet officials, Reps. Frank Pallone Jr. (N.J.) and Richard E. Neal (Mass.), the top Democrats on the House Energy and Commerce and Ways and Means committees and likely incoming chairmen, respectively, called for more information on the initial guidance issued last month.

“We are concerned that this guidance is unlawful, will raise costs for older and vulnerable Americans, and will eliminate protections for individuals with pre-existing conditions,” they wrote in a Thursday letter.

For her part, Verma insisted that “no state would be allowed to retreat from a popular aspect of the ACA that protects people with preexisting medical conditions from higher prices or an inability to buy coverage,” as Goldstein writes.

“She said that, in evaluating states’ proposals, CMS would focus on several considerations, including whether changes would foster comprehensive coverage and affordability and would not increase the federal deficit. She said federal officials would favor proposals that help, in particular, low-income residents and people with complex medical problems.”

Our Health 202 author Paige Winfield Cunningham explained last month how the recent guidance essentially expanded those so-called "guardrails," broadening them to allow "such waivers to be approved as long as people still have access to at least one comprehensive health plan and as long as states can show coverage rates wouldn’t decline in the aggregate."

And Sabrina Corlette, a senior research fellow at Georgetown University's Center on Health Insurance Reform was skeptical the ACA wouldn't be watered down via this path.

While it is “technically correct that a state cannot waive” the ACA’s provisions guaranteeing coverage for people with preexisting illnesses and protecting them from higher prices,  Corlette told me “the end result of the policies the administration put out would basically have the same effect.”

From Corlette: 

Larry Levitt, senior vice president of the Kaiser Family Foundation:

The new guidance allow Obamacare subsidies to be used for short-term and association health plans, two coverage options the administration has touted. These plans don’t cover the full range of health benefits and can refuse to cover people with preexisting conditions, as The Health 202 has written, but they offer a cheaper alternative for the people who want them.

“What would happen is those products … will attract healthier, younger enrollees, leaving a smaller and sicker pool in the ACA-compliant plans,” Corlette said

She thinks that this will lead to one of two consequences that could harm people with preexisting illnesses.

“You’re an insurance company and you’re saying, 'Okay, I can either offer these noncompliant options, get all the healthy people and subsidies to boot, or I can offer these ACA plans and get all the sick people.' What are you going to do?,” Corlette said. “You’re going to drop the ACA plans and offer these noncompliant plans. Or you can keep offering your ACA-compliant plans and jack up the price.”

Corlette said the latest recommendations continue a “trend” in the Trump administration to “break up the basic framework of the ACA.”

“They’ve been punching holes in the ACA’s minimum floor of protections for a while now,” she said. “I would say that this latest 1332 guidance and concepts is just part of that general push by the administration to sort of fray that basic national standard of protections and requirements." 


AHH: Lawmakers struck a final deal on a farm bill that gets rid of the plan supported by House Republicans and President Trump to establish new work requirements for food stamp recipients.

“The House and Senate have been deadlocked over multiple issues in the bill, including provisions in the House bill that would add new work requirements for older food stamp recipients and for parents of children age 6 and older,” my Post colleague Jeff Stein reports. “But those provisions have been stripped in the compromise package, Sen. Pat Roberts (R-Kan.), chair of the Senate Agriculture Committee, confirmed Thursday.”

“If finalized, it would break a months-long congressional impasse over legislation that doles out billions of federal dollars in food aid, agriculture subsidies and conservation funds.”

Stein writes Roberts said the White House has not yet signed off on the compromise deal but the plan is likely to gain bipartisan support in the House.

“Under current rules, most adults are required to work to receive food stamps,” he adds. “But House Republicans’ farm bill would have forced states to impose work requirements on those ages 49 to 59, an approach rejected by the Senate. The Senate also rejected the proposal to force states to impose work requirements on parents with children ages 6 to 12.”

OOF: For the first time in nearly a decade, the number of uninsured children in the country has spiked.

The number of uninsured children increased nationally, from about 3.6 million in 2016 to 3.9 million in 2017, according to new research from Georgetown University’s Center for Children and Families.

“It’s hard to isolate one factor that contributed to that sudden spike in uninsured children,” Vox’s Dylan Scott writes. “But the Georgetown researchers noted that increases were seen in every state, which suggests there was an overall national climate that contributed to the spike.”

The report notes the Republican effort to repeal the ACA, the successful repeal of the individual mandate and the Trump administration’s regulations seeking to undermine Obamacare  could have contributed to the increase. “The other most notable feature is that most of the children who lost health coverage from 2016 to 2017 live in states that refused to expand Medicaid under Obamacare: three-fourths of the 276,000, according to the Georgetown researchers,” Scott writes. “In fact, 3 in 10 uninsured kids in the US live in either Florida or Texas, the two biggest states that have refused to expand Medicaid expansion under Obamacare.”

OUCH: A new tick species capable of transmitting several deadly diseases is spreading in the United States. It’s the first invasive tick species to arrive in the United States in about eight decades, my Post colleague Lena H. Sun reports.

The Asian longhorned tick is native to eastern China, Japan, the Korean Peninsula and the Russian Far East and is also established in Australia and New Zealand.

The Centers for Disease Control and Prevention says there is no evidence so far the tick has spread diseases to humans, domestic animals or wildlife in the United States, Sun reports. But the insect has been found in Arkansas, Connecticut, Maryland, New York, North Carolina, Pennsylvania, Virginia and West Virginia after initially being discovered on a 12-year-old pet Icelandic sheep in New Jersey in August of last year.

“But public health officials are worried about the potential for Haemaphysalis longicornis to spread disease,” Sun writes. “In other parts of the world, it is a major livestock pest; its bites can make people and animals seriously ill. In some parts of Australia and New Zealand, the ticks can suck so much blood from dairy cattle that they cause milk production to drop by 25 percent, researchers have found.”

My colleague also reveals the horrifying details of how officials first learned of the ticks. An entomologist at the Hunterdon County Division of Health in New Jersey discovered the tick when “a woman who had been shearing her pet Icelandic sheep arrived at the department with what she thought were mites on her hands. Upon closer inspection, they turned out to be larval ticks. And she was covered in them.”

“She had them all over her clothing. We’re talking over 1,000 ticks on her body,” the entomologist, Tadhgh Rainey, told Sun in an interview. The woman was provided a change of clothes, and health officials still have the woman’s pants.


— The Post’s Amy Goldstein also has a deep dive on a state modeling the Trump administration’s vision to require food stamp recipients to work, even as the deal struck over the farm bill excludes such plans.

She describes the work done by ResCare, a company the state of Wisconsin hired to  “help people who are poor and sometimes hungry find work to avoid losing their food stamps.” She writes of 31-year-old Deatre McNeal, who this month “joins a large swath of poor Wisconsinites who need to document that they are working or striving to get a job for at least 80 hours a month. They must do so to receive FoodShare, the state’s version of the federal Supplemental Nutrition Assistance Program — food stamps."

“Wisconsin — with its work requirement set to expand next year and a focus on employment and training — is a role model for the Trump administration’s vision of food aid for poor Americans who could go hungry, ratcheting up what many of them are expected to do to get government help,” Goldstein adds.

Republican Gov. Scott Walker, who advanced the state’s FoodShare changes as well as “some of the nation’s most conservative revisions to other safety-net programs,” Goldstein notes, lost his bid for reelection to a third term earlier this month.

“The Democratic victor, Tony Evers, state schools superintendent, has not spoken about food aid, though he said last week that he is uncomfortable with work requirements for Medicaid that federal health-care officials recently approved at Walker’s request," Goldstein writes. "Even if Evers decides to oppose the existing work requirement for food assistance — or its expansion — the incoming governor could not reverse much of Wisconsin’s system without cooperation from the state legislature, which remains under Republican control.”

— Virginia is on track to enroll 375,000 low-income residents under its expanded Medicaid program by July 2020, beating projections of what expansion would look like when the state Assembly approved the move earlier this year.

State officials had predicted that 300,000 people would enroll in the program in the first 18 months of expansion, which is set to take effect on the first day of 2019.

“In a Capitol where Medicaid expansion came about only after a pitched five-year battle and a blue wave in the House of Delegates, the higher-than-expected enrollments have been seen in starkly different ways — either as proof of how desperately expansion was needed, or as a worrisome sign the program could swell beyond expectations,” my Post colleague Laura Vozzella reports.

“For Republicans who opposed expansion, the higher enrollment added to frustrations about a separate Medicaid issue: a $460 million cost overrun in the state’s current Medicaid program,” she adds. “That is due in part to start-up costs as the state converted care for elderly and disabled recipients to a managed-care system. That problem is unrelated to expansion, but some Republicans noted faulty estimates were at the root of both.”

Jennifer Lee, director of the state’s Department of Medical Assistance Services, said in an interview with The Post that “there’s a lot of demand and need out there for this coverage.”


— And here are a few more good reads from The Post and beyond: 


Baltimore sues Trump administration over legal immigrants’ access to public benefits (Erin Cox)

Short On Federal Funding, Obamacare Enrollment Navigators Switch Tactics (Kaiser Health News)


Democrats Taking Key Leadership Jobs Have Pocketed Millions From Pharma (Kaiser Health News)

GOP lawmakers air concerns with Trump drug pricing move in meeting with health chief (The Hill )


Bloomberg Philanthropies will donate $50 million to battle opioid epidemic (Lenny Bernstein)

How American overdose and suicide deaths have changed since 1999 (Philip Bump)


Congo Ebola outbreak is 2nd largest, 2nd deadliest (CNN)

Measles cases are up 30 percent worldwide, WHO says (NBC News)


Kevin Love Calls Speaking Out on Mental Health ‘The Biggest Thing’ in His Career (The New York Times)


Coming Up

  • The House Energy and Commerce Committee Subcommittee on Oversight and Investigations holds a hearing on "Examining the Availability of SAFE Kits at Hospitals in the United States" on Dec. 5

— 'Keep going!': Dramatic body cam footage shows narrow escape from a California wildfire:

The Butte County Sheriff’s Office released body camera video Nov. 29 of a deputy who escaped the Camp Fire in Paradise, Calif. on Nov. 8 alongside evacuees. (Video: Butte County Sheriff Office)