Thread by @charles_gaba

⚠️ I know it's a holiday weekend, but the Trump Admin is trying to cram through some terrible #ACA policies on their way out the door which the Biden Admin may or may not be able to stop. YOU can help stop this, but you only have 3 days to do so! 1/
acasignups.net/20/12/27/call-…

Every year, CMS publishes a long, wonky list of proposed changes/updates to how the #ACA is actually implemented. Some are minor, some are significant. Some are good ideas, some are bad, some are terrible. ALL are subject to a PUBLIC COMMENT period. 2/

You may assume the Trump Admin won't give a crap about these public comments, but a) the staffers actually *reviewing* them are mostly dedicated public servants who want the ACA to work; b) the comments could play a major role in *lawsuits* over policy changes later on... 3/

...and c) due to how late the Trump Admin is shoving this out the door, if they're unable to complete reviewing & responding to the comments before 1/20, it's my understanding the proposed rules can't be implemented. 4/

OK, so what are they proposing? There's over a dozen proposed changes, and about 2/3 of them are perfectly reasonable and/or minor. HOWEVER, several of them are pretty significant and would be terrible for the ACA & enrollees. 5/
acasignups.net/20/12/02/updat…

The first was already put into place *last* year, but they're proposing keeping it: They changed the Premium Adjustment Percentage Index, a formula used for calculating how much ACA enrollees receive in subsidies as well as the cap on out-of-pocket expenses (§ 156.130)(E)). 6/

By changing the way the PAPI (yeah, that's the acornym) is defined, this resulted in reduced subsidies and a higher maximum out-of-pocket expense, to the tune of up to several hundred dollars per year per enrollee. 7/

Second: They want to slash the #ACA User Fee further. HealthCare.Gov is funded (including marketing, outreach, education and the Navigator program) via a small percent of enrollee premiums, which was 3.5% for years. 8/

After news broke a few years ago that the Trump Admin was slashing HC.gov's marketing budget by *90%* from $100M to just $10M, as well as slashing the Navigator budget substantially, I became curious about where that money was going. 9/
acasignups.net/18/02/13/updat…

It turned out that at least some of it was being used by the Trump Admin to ATTACK the ACA instead of to promote it.

Setting that appalling story aside, the question of whether the 3.5% level was still appropriate was a fair one to ask. 10/
thedailybeast.com/team-trump-use…

And so, when CMS announced they were cutting the HCgov User Fee from 3.5% to 3.0% (& 2.5% for states which have their own exchange but are "piggybacking" on HCgov), I was OK with that...except that it DIDN'T include restoration of the marketing, outreach or navigator budgets. 11/

HOWEVER...now they're proposing slashing the User Fee even *MORE*. (§ 156.50(C)), by another 25 - 30%.

The Biden Admin is going to need whatever resources it can to improve & strengthen the ACA. Rebuilding HCgov is part of that. The fees should stay as is. 12/

These first two are small potatoes, though. It's the other three which I'm far more concerned about.

#3: CMS is proposing to effectively codify Seema Verma's appalling 2018 "interpretation" of the ACA's Section 1332 State Innovation Waiver provision. 13/
acasignups.net/18/11/29/red-a…

1332 waivers are *supposed* to give states the ability to change some ACA provisions AS LONG AS the changes ensure that a) at least as many people receive healthcare coverage as otherwise would; which is b) at least as comprehensive, while c) not raising the federal deficit. 14/

Unfortunately, a couple of years ago Verma made some radical changes to how she "interprets" Section 1332 guidance in such a way that states could abandon ACA exchanges altogether and give federal ACA subsidies intended for ACA-compliant policies only to junk plans. 15/

So far only one state, Georgia, has taken Verma up on her new "definition" of Section 1332. She approved it last month, and if it's implemented as planned in 2023, thousands of Georgians would lose coverage while confusion would reign. 16/
cbpp.org/research/healt…

Via 31 CFR Part 33 & 45 CFR Part 155 of the proposed 2022 #NBPP, however, her "interpretation" of 1332 waivers would be made into official HHS policy, making it harder to reverse. Not only shouldn't this happen, Verma's 2018 "definition" should be abandoned altogether. 17/

The next item of major concern relates to this OTHER lonnnng thread I posted a few days ago, regarding 3rd-party Direct Enrollment entities (basically, private web broker sites authorized to sell #ACA policies). 18/

https://twitter.com/charles_gaba/status/1342168788716953603

As I. note in that thread, the problem isn't allowing 3rd-party ACA exchange sites to operate in & of itself; as long as they're *properly regulated*, *only sell ACA plans* and list *all* ACA plans without undue bias, that's fine with me. One even has a banner ad on my site. 19/

The problem is, some 3rd-party sites sell non-ACA compliant "plans" as well...many of which are either junk, have massive coverage gaps, deny coverage of pre-existing conditions...and some have a history of fraud. This is EXACTLY what the ACA exchanges were designed to AVOID. 20/

That brings me to part 155.220(c)(3)(iii) of the 2022 #NBPP, which would ACTIVELY PROMOTE ACA navigators/assisters to push enrollees towards these 3rd-party sites instead of the official exchanges (using what little navigator funding they're still providing). 21/

The Trump Admin's "justification" for this move is that they claim 3rd-party sites have additional functionality not available via HC.gov. If so, the obvious solution is to ADD functionality to https://t.co/Q779GjOi9c, not to push people away from it. 22/

And that brings me to the last item: 155.221(j).

This proposal would take what Seema Verma is allowing Georgia to do *and* what the last item would do to the next level: It would allow ANY state to abandon HC.gov ALTOGETHER. 23/

When I say "abandon HC.gov", I don't mean "switch to their own official state-based exchange site" as Nevada did last year or as Pennsylvania & New Jersey have done this year. I mean it would let states abandon ANY official ACA exchange AT ALL. 24/

If this happened, someone wanting to enroll in an #ACA policy in, say, Texas wouldn't go to HC.gov. They wouldn't even go to an official TX ACA site. They'd go to a private, 3rd-party broker which might try to hawk junk plans alongside ACA plans. 25/

What if you're eligible for Medicaid? Well, Texas hasn't bothered expanding Medicaid under the ACA anyway, but even if they did, would the 3rd-party site point someone eligible for the public program in the right direction? Maybe...or maybe not. 26/

Would they list EVERY ACA plan, or only those which they receive the highest commission on? Would they list all of the information about the policies they list, or would they leave some details out?

These are the EXACT reasons official ACA exchanges are baked into the law. 27/

⚠️ OK, so how do you submit a comment? It's actually pretty easy!

First, go here: regulations.gov/document?D=CMS… 28/

Click the "Comment Now" button on the right, type in your comment (and/or attach a text file with it), plug in your name and click Continue. Voila!

You can also review the comments which have already been submitted here: regulations.gov/docketBrowser?…

Remember to be *polite*. Again, it's not Alex Azar or Seema Verma who will be reviewing these; it's the career staffers at CMS.

Alternately, you can also use this link: federalregister.gov/documents/2020…

Here's the link to review current comments via the second site. It may take a day or two for your comment to be publicly listed: beta.regulations.gov/document/CMS-2…

Finally, remember that your comment has to be submitted NO LATER THAN MIDNIGHT ON WEDNESDAY.

Thank you!
acasignups.net/20/12/27/call-…

FOLLOWUP: You don't have to be a healthcare wonk to care about this stuff or to submit comments. While being more specific is generally preferred, not every comment goes into the weeds. The main points in my own wonky comment boild down to the following:

🚨 UPDATE: The *first* comment submission link upthread won't work today because "Regulations.gov redirects to the beta site on Tuesdays & Thursdays." Use the SECOND link (to the Federal Register) today instead: federalregister.gov/documents/2020…

UPDATE: We're up to at least 190 comments, thank you!

Let's keep it going--remember, the official deadline is Wednesday at midnight, but it's strongly advised to submit your comment no later than *5:00pm Eastern time* to make sure it's considered:

acasignups.net/20/12/29/call-…

⚠️ UPDATE: We're up to at least 220 comments, thank you!

Let's #KeepItGoing! Remember, the official deadline is midnight tonight, but it's STRONGLY ADVISED to submit your comment no later than *5:00pm TODAY* to make sure it's considered!
acasignups.net/20/12/29/call-…

Here's the direct link again: beta.regulations.gov/document/CMS-2…