Don't Be Fooled: $15 Billion More for House GOP Health Bill’s Stability Fund Will Undo Little of Bill’s Harm on Mental Illness and Substance Use Disorders
The Affordable Care Act struck a popular chord by allowing adult children to obtain health coverage through a parent’s plan until their 26th birthday.
Now, seeking broad support for their efforts to repeal and replace the ACA, House Republicans have kept that guarantee intact. But it’s not clear whether that provision will be successful or a destabilizing force in the insurance marketplace.
The policy has proven to be a double-edged sword for the ACA’s online health exchanges because it has funneled young, healthy customers away from the overall marketplace “risk pool.” Insurers need those customers to balance out the large numbers of enrollees with chronic illnesses who drive up insurers’ costs — and ultimately contribute to higher marketplace premiums.This KHN story also ran in CNN Money. It can be republished for free (details).
Joseph Antos, a health economist with the American Enterprise Institute, a Washington, D.C.-based conservative think tank, said the ability for young adults to stay on family plans represents a “critical mistake” within the health law, cutting off insurers from a large, healthy demographic that likely would be able to afford a health care plan.
“This is essentially an ideal group for an insurance company,” he said. “They’re not going to use many services, and they’re going to pay their bills.”
The young-adult provision went into effect in September 2010 and families put it to use quickly, with many young adults leaving their own insurance plans. A report published by the Centers for Disease Control and Prevention in 2013 found the percentage of adults ages 19 to 25 with personal plans fell from nearly 41 percent in 2010 to just over 27 percent in 2012, while the ratio of those covered through a family member’s plan rose by 14 percentage points.
And the Department of Health and Human Services said last year that final 2016 marketplace enrollment numbers showed more than 6 million people ages 19 to 25 gained insurance through the health law, including 2.3 million who went onto their family health plan between September 2010 and when online marketplaces began operating in 2014.
Cara Kelly, a vice president of the health care consulting firm Avalere Health, said the provision’s effect must be understood in the context of the law’s implementation. Affordability and the selection of plans available in the marketplace also could have influenced the decision among young adults to buy or shirk insurance, Kelly said. Even if the provision had not been included in the law, she said, one can’t assume that the young adults would have signed up for coverage.
A little more than a quarter of marketplace customers in 2016 were adults ages 18 to 34, according to data from the Department of Health and Human Services. But federal officials and insurers had hoped for higher rates, noting that the group made up about 40 percent of the potential market.
Public support for the young-adult provision makes it difficult to take away. A survey conducted by the Kaiser Family Foundation in December 2016 found that 8 in 10 Republicans and 9 in 10 Democrats favored the benefit. (Kaiser Health News is an editorially independent program of the foundation.)
“It has been extremely popular,” said Al Redmer Jr., the Maryland insurance commissioner and chairman of the health insurance and managed care committee within the National Association of Insurance Commissioners. “So with that being the case, I don’t know if politically there’s an appetite to unwind it.”
Republicans have opted for different measures than the ACA to attract increased numbers of healthy, young customers and make the risk pools vibrant. To keep prices lower for these customers, the bill allows insurers to charge older people up to five times more than young adults. Under the ACA, that difference is 3-to-1, and Republicans say that made prices too expensive for younger customers.
It would also replace the health law’s individual mandate — the requirement that almost everyone have health insurance or face a penalty — with a 30 percent surcharge on their premium for late enrollment or allowing your insurance to lapse for more than 63 days within a year.
The overall effect, according to an analysis conducted by the Congressional Budget Office, would be a more stable market with a larger number of healthy enrollees. The report also estimated the bill could result in 24 million more people being uninsured.
But the bill also has disincentives for those young people. To help pay for premiums, low-income people will get tax credits based on age and household income. Older people would get $4,000 per year, twice as much as younger customers.
Insurers have reacted cautiously. The insurer Blue Cross Blue Shield Association released a statement this month expressing its support for increasing affordability for younger enrollees. But it also raised concerns about the Republicans’ tax credit proposal. A benefit based on age alone “does not give healthy people enough incentive to stay in the market, especially in the absence of an individual mandate.”
The insurance trade group America’s Health Insurance Plans sent a letter to House Republican committee chairmen voicing support for the 5-to-1 age-band rating and tax credits based on age.
“We have stated previously that there is no question that younger adults are under-represented in the individual market,” the letter said. “Recalibrating and reforming the way in which the premium assistance is structured will encourage younger Americans to get covered.”
KHN reporter Mary Agnes Carey contributed to this article.
A last-minute attempt by conservative Republicans to dump standards for health benefits in plans sold to individuals would probably lower the average consumer’s upfront insurance costs, such as premiums and deductibles, said experts on both sides of the debate to repeal and replace the Affordable Care Act.
But, they add, it will likely also induce insurers to offer much skimpier plans, potentially excluding the gravely ill, and putting consumers at greater financial risk if they need care.
For example, a woman who had elected not to have maternity coverage could face financial ruin from an unintended pregnancy. A healthy young man who didn’t buy drug coverage could be bankrupted if diagnosed with cancer requiring expensive prescription medicine. Someone needing emergency treatment at a non-network hospital might not be covered.
What might be desirable for business would leave patients vulnerable.
“What you don’t want if you’re an insurer is only sick people buying whatever product you have,” said Christopher Koller, president of the Milbank Memorial Fund and a former Rhode Island insurance commissioner. “So the way to get healthy people is to offer cheaper products designed for the healthy people.”Use Our ContentThis KHN story can be republished for free (details).
The proposed change could give carriers wide room to do that by eliminating or shrinking “essential health benefits” including hospitalization, prescription drugs, mental health treatment and lab services from plan requirements — especially if state regulators don’t step in to fill the void, analysts said.
The Affordable Care Act requires companies selling coverage to individuals and families through online marketplaces to offer 10 essential benefits, which also include maternity, wellness and preventive services — plus emergency room treatment at all hospitals. Small-group plans offered by many small employers also must carry such benefits.
Conservative House Republicans want to exclude the rule from any replacement, arguing it drives up cost and stifles consumer choice.
On Thursday, President Donald Trump agreed after meeting with members of the conservative Freedom Caucus to leave it out of the measure under consideration, said White House Press Secretary Sean Spicer. “Part of the reason that premiums have spiked out of control is because under Obamacare, there were these mandated services that had to be included,” Spicer told reporters.
Pushed by Trump, House Republican leaders agreed late Thursday to a Friday vote on the bill but were still trying to line up support. “Tomorrow we will show the American people that we will repeal and replace this broken law because it’s collapsing and it’s failing families,” said House Speaker Paul Ryan (R-Wis.). “And tomorrow we’re proceeding.” When asked if he had the votes, Ryan didn’t answer and walked briskly away from the press corps.
But axing essential benefits could bring back the pre-ACA days when insurers avoided expensive patients by excluding services they needed, said Gary Claxton, a vice president and insurance expert at the Kaiser Family Foundation. (Kaiser Health News is an editorially independent program of the foundation.)
“They’re not going to offer benefits that attract people with chronic illness if they can help it,”said Claxton, whose collection of old insurance policies shows what the market looked like before.
One Aetna plan didn’t cover most mental health or addiction services — important to moderate Republicans as well as Democrats concerned about fighting the opioid crisis. Another Aetna plan didn’t cover any mental health treatment. A HealthNet plan didn’t cover outpatient rehabilitative services.
The House replacement bill could make individual coverage for the chronically ill even more scarce than a few years ago because it retains an ACA rule that forces plans to accept members with preexisting illness, analysts said.
Before President Barack Obama’s health overhaul, insurers could reject sick applicants or charge them higher premiums.
Lacking that ability under a Republican law but newly able to shrink benefits, insurers might be more tempted than ever to avoid covering expensive conditions. That way the sickest consumers wouldn’t even bother to apply.
“You could see even worse holes in the insurance package” than before the ACA, said Sabrina Corlette, a research professor at the Center on Health Insurance Reforms at Georgetown University. “If we’re going into a world where a carrier is going to have to accept all comers and they can’t charge them based on their health status, the benefit design becomes a much bigger deal” in how insurers keep the sick out of their plans, she said.
Michael Cannon, an analyst at the libertarian Cato Institute and a longtime Obamacare opponent, also believes dumping essential benefits while forcing insurers to accept all applicants at one “community” price would weaken coverage for chronically ill people.
“Getting rid of the essential health benefits in a community-rated market would cause coverage for the sick to get even worse than it is under current law,” he said. Republicans “are shooting themselves in the foot if they the offer this proposal.”
Cannon favors full repeal of the ACA, allowing insurers to charge higher premiums for more expensive patients and helping consumers pay for plans with tax-favored health savings accounts.
In an absence of federal requirements for benefits, existing state standards would become more important. Some states might move to upgrade required benefits in line with the ACA rules but others probably won’t, according to analysts.
“You’re going to have a lot of insurers in states trying to understand what existing laws they have in place,” Koller said. “It’s going to be really critical to see how quickly the states react. There are going to be some states that will not.”
Mary Agnes Carey and Phil Galewitz contributed to this story.
One of the harshest rules in the Supplemental Nutrition Assistance Program (SNAP, formerly known as food stamps) limits unemployed individuals aged 18 to 50 not living with children to three months of SNAP benefits in any 36-month period when they aren’t employed or in a work or training program for at least 20 hours a week. Under the rule, implemented as part of the 1996 welfare law, states are not obligated to offer all individuals a work or training program slot, and most do not. SNAP recipients’ benefits are cut off afte
The United Nations’ World Meteorological Organization (WMO) provides the framework for international cooperation on weather issues that know no political boundaries. This year’s theme for the event is “Understanding Clouds,” and their website has many resources on how to identify different types of clouds and their importance. They also have a flickr page with some incredible photos featuring clouds.
The WMO has a mandate to focus on weather, climate, and water, which includes their focus areas of energy, environment, natural hazards and disaster risk reduction, oceans, polar and high-mountain regions, public health, and urban development – megacities. They supply policy documents and standards, technical regulations, and guides for the international community, as well as Meteoterm, a thesaurus of specialized terminology for the international meteorological community.
Additionally, the WMO offers education and training to the global community to meet education needs and professional development, especially for those members that do not have access to those services. Those education and training resources focus on meteorology, weather forecasting, and climate and climate prediction, but also agriculture, aviation, environment, hydrology, information and communication technology, and cross-cutting areas.
In the United States, several agencies from different departments contribute to our knowledge and research on weather, meteorology, and the environment:
- the National Oceanic and Atmospheric Administration from the U.S. Department of Commerce runs the National Weather Service;
- the National Park Service under the U.S. Department of the Interior monitors air quality and ozone and meteorology;
- the U.S. Geological Survey, also a part of the U.S. Department of the Interior, provides information on current conditions, natural hazards, and the impacts on health of climate and the environment;
- the U.S. Department of Agriculture has a Disaster Resource Center and resources on climate solutions; and
- the Environmental Protection Agency studies and teaches about the environment as well as develops and enforces regulations to implement environmental laws passed by Congress.
In commemoration of World Meteorological Day, I found many Law Library of Congress resources that mention weather and meteorology, including the focus areas of the WMO:
- In the Global Legal Monitor, Sayuri has covered active volcanoes in Japan, Wendy discussed a border agreement with meteorological implications in China and Vietnam, Connie reviewed the transition of state-owned enterprises to semi-private corporations in several fields including meteorology and air traffic control in Vietnam and Indonesia, and Connie also discussed the ratification of the ASEAN Regional Haze Agreement by Indonesia.
- The Global Legal Research Directorate has also tackled the focus areas from the WMO with reports like Legislation on Use of Water in Agriculture, Japan: Legal Response to the Great East Japan Earthquake of 2011, Legal Responses to Health Emergencies, and New Zealand: ‘Climate Change Refugee’ Case Overview.
- In Custodia Legis has focused on weather with former Law Librarian David Mao’s blog post on severe weather shelters in Minnesota and I previously wrote about the United Nations International Day of Human Space Flight, which would not be possible but for advances in meteorology.
- The Inside Adams blog has a great post on resources for science teachers and a post about a House Science Committee briefing related to weather. And the Library of Congress blog discussed the weather as an omen at Lincoln’s second inauguration.
- A search through the Statutes at Large found 411 references to “weather” or “meteorology.” Many of statutes include appropriations. There is an act to transfer the Weather Service to the Department of Agriculture and acts to establish storm-warning stations in Lake Michigan and weather bureau stations in Lake Huron.
- In the United States Treaties and International Agreements from 1776-1949, my search found 22 treaties with references to “weather” or “meteorology” concerning international cooperation on meteorology and weather. The World Meteorological Organization, meteorological program cooperation with the Philippines, North Atlantic Ocean weather stations, and weather stations cooperation with Mexico are just some examples.
- Finally, the Federal Register has thousands of results with “weather” or “meteorology.” Because there are so many, you can use the facets on the left-hand side of the page to narrow down your results. The downloads are large, but you can search the file to direct you to the words you are looking for.
Celebrate today by contemplating the weather and looking at the clouds!
We’ve explained that eliminating the Affordable Care Act’s (ACA) minimum benefit standards (“Essential Health Benefits,” or EHB) for individual and small-group market plans, as House Republican leaders are reportedly considering, would likely leave many people with pre-existing conditions unable to find coverage at any price, cause women to be charged mo
The House Republican health care plan would impose on Alaska the nation’s largest cut in premium tax credits, a five-fold increase in state costs for new enrollees if Alaska wanted to maintain its Medicaid expansion, and the elimination of key health benefits for Alaska Natives. While the plan would seriously harm all states, Alaska would face a “perfect storm” of detrimental effects that would gut its Medicaid program, destabilize its individual health insurance market, and widen disparities in health coverage. In short, Alaskans would likely lose more under the House plan than residents
The White House and House Republican leaders are reportedly negotiating with House Freedom Caucus members to eliminate federal minimum benefit (“Essential Health Benefits”) standards for individual and small-group market plans as part of the House health bill. That would leave many people with pre-existing conditions unable to find the coverage they need at any price, much less an affordable one; result in women being charged more than men; and expose many people with h