I’m reading the new 1332 waiver guidance document now.
First up: New jargon.
s3.amazonaws.com/public-inspect…
First up: New jargon.
s3.amazonaws.com/public-inspect…
The new guidance prioritizes private over public insurance. This could make it harder for states to get waivers for, say, a single-payer system, one of the original purposes of the program. Also, could make Medicaid buy-in hard.
This looks to be a slightly new goal. ACA says only that the plans shouldn't increase federal spending.
This is also new. 1332 nerds: Is this related to *anything* in the legislative text?
This is wonky, but is actually a big change. The current rule is that coverage needs to be at least as comprehensive as it would be under Obamacare rules. The Trump admin is now saying that insuring more people matters more than insurance quality.
The standard seems to be that, as long as ACA-compliant coverage is available for those who want it, states can encourage less comprehensive coverage options alongside it.
Sort of sounds a lot like the Cruz amendment from last year. nytimes.com/2017/07/05/ups…
But if you think the exchange market is, effectively, a high risk-pool, as some in the administration do, this approach dovetails with other changes they have made. nytimes.com/2018/04/11/ups…
The guidance seems to eliminate the current requirement that states must pass legislation to enact innovation waivers. Now, it appears, an executive order or regulation will be enough in most states. This mirrors the approach in last year's Obamacare repeal/replace bills.
The administration is going to measure affordability broadly, to include out-of-pocket spending as well as insurance premiums. I wonder how states will measure that if they are offering options with fewer benefits than under ACA rules.
Nevertheless, the administration plans to count enrollment in short-term health plans as "coverage" for the purposes of the waiver calculation. Some details on what short-term plans do and don't cover here: nytimes.com/2018/08/01/ups…
Here's how CMS is asking states to justify their estimates of coverage and cost under waiver proposals.
Interesting. Healthcare.gov is apparently now functional and flexible enough that it could work with varying state rules and program. What a long way that website has come.
This is a good reminder that, as written, 1332 doesn't really allow changes to state Medicaid programs. Coordinating two sets of waivers will remain clunky. The Alexander/Murray stabilization bill that died on the Hill would have helped coordinate these programs.
Ok, a less nerdy step back: The Trump administration is overhauling a program that allows states to toss out nearly all the Obamacare rules to refashion its health insurance system for middle- and high-income Americans who buy their own insurance.
And it's doing so in a way that's designed to make it easier for states to get these plans approved, and easier for states to pursue plans that include coverage that is skimpier than would be allowed under Obamacare's normal rules.
There are strong echoes of elements of last year's GOP health care legislation.
The Trump administration has been enthusiastic about these waivers from the outset, and has approved several this year, in both red and blue states, to enact reinsurance programs.
On a press call, Seems Verma says she’s received “numerous state requests” for a more liberal 1332 process.
(The Iowa proposal comes to mind: iid.iowa.gov/iowa-stopgap-m…)
Verma really emphasizing that this will not hurt people with preexisting conditions. But, in the analysis of the Cruz plan, a lot of smart health economists thought the splitting of the market could raise prices for such people. nytimes.com/2017/07/05/ups…
CMS is going to put out a "series of waiver concepts," to give states a sense of the kinds of plans they might approve. Should be really interesting to see what these models look like.
Verma confirms that states could be permitted to use federal subsidy dollars to help people buy short-term health plans under a 1332 waiver.
The new guidance goes into effect right away, but any new system wouldn't be up and running before 2020.
I am super curious about why CMS chose to make this announcement now, right before the election, when pre-existing conditions protections are such a hot issue.
I do think it potentially hands some GOP candidates a talking point about non-Obamacare ways to protect this population. But 1332 IS part of Obamacare,
This change, along with many other Trump admin health care changes will tend to widen the differences between the states on what health insurance looks like and who can afford it. nytimes.com/2018/02/28/ups…
Seema Verma has a blog post about the new innovation waiver guidance. cms.gov/blog/new-state…
Like recent speeches from her and from HHS Secretary Alex Azar, there's a big of a mixed message here. 1) Obamacare is doomed. 2) The Trump administration has fixed it.
