HealthCare.gov enrollment is down, while State-based Marketplace enrollment is up at the end of 2017 open enrollment; Hawaii, Massachusetts and Oregon introduce legislation to codify ACA reforms in state law in case of repeal; and Indiana requests an extension of its Medicaid expansion waiver.

FEDERAL AND STATE MARKETPLACE NEWS:

2017 Open Enrollment Ends, Enrollment Up in State-Based Marketplaces but Down on HealthCare.gov

The 2017 open enrollment period ended on January 31, with 9.2 million people signing up for coverage on HealthCare.gov, about 400,000 fewer than last year. Enrollment from January 15-31 was approximately half of enrollment during the same two week period last year, attributed by some to the Trump Administration’s decision to pull advertisements and some outreach for HealthCare.gov in the final weeks of open enrollment. Many State-based Marketplaces saw increased enrollment this year, and some saw record enrollment.

• California: Covered California reached total enrollment of 1.5 million people for 2017. California extended open enrollment by four days for individuals who began applications by the original deadline of January 31.
• Colorado: Approximately 176,000 individuals selected a 2017 plan through Connect for Health Colorado, a 12% increase from 2016. Connect for Health Colorado extended its enrollment deadline to February 3 for consumers who began applications by January 31, in response to a “surge in sign-ups.”
• Maryland: Approximately 158,000 residents enrolled in qualified health plans through Maryland Health Connection, down from approximately 162,650 in 2016.
• Massachusetts: Over 246,000 individuals enrolled in Health Connector coverage during open enrollment, the highest number since ACA implementation.
• New York: More than 240,000 New Yorkers enrolled in Qualified Health Plans and more than 665,000 in Essential Plan coverage through the State’s Marketplace during this year’s open enrollment. Total enrollment increased 28% from 2016.
• Vermont: Nearly 18,000 Vermonters signed up for 2017 coverage through the State-based Marketplace, approximately 3,000 more than in 2016.

One-Third of Counties Have Only One Marketplace Insurer in 2017

The number of counties with only one ACA Marketplace insurer increased from 7.2% in 2016 to 32.8% in 2017, and the number of counties with two Marketplace insurers increased from 29% to 37%, according to a Heritage Foundation brief. Since the launch of the Marketplaces in 2014, the number of participating insurers per state has declined by 13.8%.

FEDERAL AND STATE HEALTH REFORM ACTIVITY:

Low-Income Adults Report Improved Insurance Affordability and Coverage Gains Since ACA

The number of working-age adults who reported difficulty finding affordable insurance dropped by nearly 50% between 2010 and 2016, according to findings from the 2016 Commonwealth Fund Biennial Health Insurance Survey. Uninsurance rates for low-income adults dropped 47% over the same period, with young adults ages 19 to 34 experiencing the largest coverage gains.

White House Clarifies "Two-for-One" Executive Order

The White House issued new guidance Thursday explaining President Trump’s January 30 executive order that requires federal agencies to eliminate two existing regulations for every new regulation issued. Healthcare regulations with significant economic impact would be affected by the order, although some regulations may be exempted, including regulations that address health or safety emergencies, govern solely federal spending, or have no cost impact on stakeholders.

Hawaii: Legislation Would Preserve Core Elements of ACA

Companion bills introduced by key leadership in the Hawaii House and Senate would preserve many core ACA reforms under State law in the event of repeal, including an individual health insurance mandate, and the requirement that insurers offer ten essential health benefits. The bills would also extend dependent coverage to adult children under the age of 26, and prohibit insurers from imposing a pre-existing condition exclusion or offering different premiums based on gender. The Senate bill has passed committee, while the House bill is awaiting a committee hearing.

Massachusetts and Oregon: States Move to Preserve ACA Family Planning Coverage Requirements

In anticipation of potential repeal of the ACA, Massachusetts and Oregon lawmakers have introduced legislation that would preserve or expand ACA family planning coverage requirements, including mandating that insurers cover contraceptives with no cost-sharing. Additionally, the Massachusetts bill would allow individuals to switch contraceptive methods without seeking authorization from their insurer, and the Oregon bill would require insurers to cover a variety of other reproductive health services, including well-women care, prenatal care, counseling and screening for sexually-transmitted diseases, and breastfeeding support.

STATE MEDICAID EXPANSION UPDATES:

Indiana: State Submits Medicaid Waiver Extension Application to CMS, With Amendments

The State submitted a three-year 1115 waiver extension application for its Medicaid expansion program, known as the Healthy Indiana Plan 2.0, with some amendments, including: coverage lock-outs if required redetermination paperwork is not completed in a timely manner; higher premiums for smokers; continuing waiver coverage for women who become pregnant while enrolled under the waiver, rather than enrolling them in traditional Medicaid; and expanded access to substance use disorder services. The State’s waiver expires in January 2018; if approved, the extension would be valid through December 2020. Medicaid expansion in Indiana covers nearly 400,000 individuals with incomes up to 138% of FPL through high-deductible health plans. Deductibles are funded by the enrollee’s POWER account, a health savings-like account funded by a combination of enrollee contributions, Medicaid funds, and in some instances, contributions from employers and other third parties.

Indiana and Michigan: Premiums May Deter Medicaid Enrollment Under Waivers

Premiums and complex enrollment policies, key features of Indiana’s and Michigan’s Medicaid expansion waivers, may deter Medicaid enrollment, according to a Kaiser Family Foundation analysis of waiver implementation in Indiana and Michigan. The brief also finds that health savings accounts and healthy behavior incentives, both included in Indiana and Michigan’s waivers, may be challenging for consumers and stakeholders to understand without sufficient educational outreach.

Michigan: Uncompensated Care Costs Dropped by 48% After Medicaid Expansion

Uncompensated care costs for Michigan hospitals were 2.9% of total costs in 2015, down from 5.2% in 2013 before the State expanded Medicaid, according to a University of Michigan report. In 2013, hospitals spent a total of $627 million on uncompensated care, compared to $327.1 million in 2015.

Nevada: Governor Proposes $20 Million Decrease to State Mental Health Budget in Light of Medicaid Expansion

Governor Brian Sandoval's (R) 2017-2019 executive budget proposed a $20 million reduction in State mental health funding; Department Director Richard Whitley noted the State's expansion of Medicaid has increased access to behavioral health services under Medicaid, reducing use of State-funded behavioral health services, according to the Reno Gazette-Journal. Advocates, however, raised concerns with this funding cut in light of federal discussions about repealing the ACA and Medicaid expansion.

Ohio: Proposed Executive Budget Maintains Medicaid Expansion

Governor John Kasich's (R) 2017-2018 executive budget recommends maintaining coverage for Ohio's Medicaid expansion population and proposes that childless adults with incomes “above poverty” pay a $20 monthly Medicaid premium. The premium proposal, which is projected to save Ohio $200 million over two years, would require federal approval under a waiver. Additional budget proposals include a reduction in hospital and nursing home provider rates and implementation of a provider tax on managed care companies.

FEDERAL AND STATE MEDICAID REFORM ACTIVITY:

CHIP Health Services Initiatives Can Help Fund State Lead Abatement Efforts

A new brief from Manatt Health provides an overview of how states can use health services initiatives (HSIs) under the Children’s Health Insurance Program’s (CHIP) to leverage federal funding for health programs for low-income children, including those that support lead exposure testing, prevention and abatement. HSIs are a long-standing but relatively underutilized CHIP provision that do not require a waiver from CMS.

Urban Institute Publishes Series on Medicaid Coverage for Justice-Involved Individuals

The Urban Institute published a series of briefs reviewing how states can utilize Medicaid to facilitate enrollment in health coverage and access to care for justice-involved individuals. The five briefs highlight specific state initiatives to: improve information exchange between Medicaid and correctional agencies; improve continuity of care for justice-involved individuals through Medicaid health homes; connect justice-involved individuals to community-based case management and care coordination services; ensure continuous access to medication for justice-involved people; and, use peer educators in prisons to conduct pre-release transition planning for people with serious chronic health conditions.

Florida: Governor Proposes Cutting More Than $900 Million in Medicaid Spending to Hospitals

Governor Rick Scott (R) proposed cutting $581 million in Medicaid managed care hospital payments, $298 million in supplemental payments to nonprofit hospitals, and $50 million from automatic Medicaid hospital rate increases, as part of his fiscal year 2018 budget proposal.

STATE STAFFING UPDATES:

Iowa: Doug Ommen Appointed Insurance Commissioner

Doug Ommen, who had been serving as acting Insurance Commissioner since December 2016, was named Insurance Commissioner by Governor Terry Branstad (R). Ommen was previously Missouri’s Insurance Commissioner before joining Iowa's insurance division in 2013.

New Mexico: New Mexico’s State-Based Marketplace Appoints New CEO

BeWellnm, New Mexico’s State-based Marketplace, has appointed Cheryl Smith Gardner as the new CEO starting in March 2017. Smith Gardner is currently the Executive Director of the Arkansas Health Insurance Marketplace, and previously served as Director of Policy and Strategy for Utah’s State-based Marketplace.

North Carolina: Former CMS Official Assumes Role as Secretary of Health and Human Services

Dr. Mandy Cohen, most recently the Chief Operating Officer and Chief of Staff at the Centers for Medicare and Medicaid Services (CMS), assumed the role of Secretary of Health and Human Services on Monday, January 30, 2017, following her nomination by Governor Roy Cooper (D). Dr. Cohen is scheduled for a confirmation hearing by the state Senate on March 16, under a new law requiring Senate approval for Cabinet appointments, which is subject to an ongoing lawsuit by Governor Cooper.

Texas: David Mattax Reappointed Insurance Commissioner

David Mattax, who has served as the State’s Commissioner of Insurance since January 2015, was reappointed by Governor Greg Abbott (R) for an additional term that will expire on February 1, 2019.