Manatt Health Introduces Two New Publications: Ongoing Insights into the Latest Healthcare Issues and Actions

In this time of uncertainty for healthcare, real-time, insightful information on key developments is more important than ever. To ensure our publications evolve with your needs, Manatt Health will be replacing “Manatt on Health Reform” with two new monthly publications that will help you better track and respond to the emerging policies, legislation and innovations that are reshaping our healthcare environment. “Manatt on Health” will deliver timely updates and analyses of federal and state health reform initiatives. “Manatt on Health: Medicaid Edition” will provide a deeper dive into major Medicaid topics, including the latest news from across the states. This will be the last issue of the Weekly Highlights newsletter. Watch your inbox in July for our new publications, and thank you for reading.

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CBO estimates 22 million lose coverage under the Senate health bill; governors and other stakeholders react with concern; and new analyses highlight potential impacts of the bill.

SENATE HEALTH BILL ACTIVITY AND ANALYSIS:

Updated BCRA Draft Includes Continuous Coverage Provision

An updated version of the BCRA discussion draft released by Senate Republicans on Monday imposes a six-month waiting period for individual market coverage for any enrollee that cannot demonstrate 12 months of continuous creditable coverage without a 63‐day break prior to enrollment, effective January 1, 2019. Individuals who maintain continuous coverage without a significant break are not subject to the waiting period, and are eligible for guaranteed issue coverage without medical underwriting, as under the ACA. Senate Republican leadership has delayed a vote on the bill until after the July 4 recess.

CBO Estimates 22 Million Would Lose Coverage Under BCRA

CBO estimates that the updated BCRA will increase the number of uninsured by 22 million by 2026, compared to current law; CBO previously estimated that 23 million would be uninsured in 2026 under the House-passed AHCA. CBO estimates that 15 million of the newly uninsured would have been Medicaid enrollees under current law, and 7 million would have been enrolled in the Marketplace. CBO also finds that the bill cuts $772 billion in federal Medicaid funding over ten years. CBO notes that the individual market will remain stable in most areas of the country, with premiums decreasing by 20% on average by 2026, however the value of coverage will be significantly lower compared to the ACA and older and lower-income enrollees will drop coverage in response to higher out-of-pocket costs.

Governors and Stakeholders React to BCRA

Nearly a dozen Republican senators have reportedly expressed reservations with the current version of the BCRA, though most have signaled a willingness to negotiate. Meanwhile, a number of influential Republican governors and national associations are speaking out in opposition to the bill.

Governors Reactions

• Alaska: Governor Bill Walker (I) said that he is “deeply concerned about the potential effects of a one-size-fits-all approach” in Alaska.
• Indiana. Governor Eric Holcomb (R) said that he would “thoroughly examine” the Senate bill, while also noting recent insurer exits from the State’s Marketplace.
• Massachusetts: Governor Charlie Baker (R) stated, “upon a first review, this version falls short and will result in significant funding losses for our State.”
• Nevada. In a joint press conference, Nevada Senator Dean Heller (R) and Governor Brian Sandoval (R) announced their opposition to the bill. Governor Sandoval expressed particular concerns around the phase-out of Medicaid expansion, which would impact 210,000 Nevadans.
• Ohio: Governor John Kasich (R) said he has “deep concerns” with the bill’s potential impacts, particularly for those with drug addiction, mental illness, and chronic health issues.

Trade/Advocacy Associations

• AARP: “We strongly urge the Senate to reject this bill.”
• American Academy of Pediatrics: “The U.S. Senate's health care legislation, at last unveiled today, fails to meet children's needs.”
• American Cancer Society: “The proposed legislation appears to significantly weaken the ability of millions of cancer patients, survivors and those at risk for the disease to find and afford adequate, meaningful health care coverage.”
• American College of Physicians: “The BCRA does not meet—or come close to meeting— the criteria that ACP established that any reforms to current law should first, do no harm to patients.”
• American Hospital Association: “We urge the Senate to go back to the drawing board and develop legislation that continues to provide coverage to all Americans who currently have it.”
• American Medical Association: “Medicine has long operated under the precept of Primum non nocere, or ‘first, do no harm.’ The draft legislation violates that standard on many levels.”
• America’s Essential Hospitals: “Today’s Senate bill makes few material improvements to the deeply damaging House legislation, and might be worse overall.”
• Catholic Health Association: “CHA is strongly opposed to the Senate Better Care Reconciliation Act.”
• Chamber of Commerce: The bill “will provide millions of Americans outside of the employer-based system with more options for coverage at lower costs.”
• Federation of American Hospitals: “Now is the time for the Senate to hit reset and make key improvements to this legislation.”
• National Association of Medicaid Directors: “Medicaid Directors recommend prioritizing the stabilization of Marketplace coverage. Medicaid reform should be undertaken when it can be accomplished thoughtfully and deliberately… No amount of administrative or regulatory flexibility can compensate for the federal spending reductions that would occur as a result of this bill.”
• National Governors Association: “We urge [Congress] to give states sufficient time to review the legislation before proceeding.”

Colorado: $15 Billion in Federal Funding Would Be Eliminated Under Senate Bill

The rollback of funding for Medicaid expansion would lead to 628,000 fewer Medicaid enrollees in Colorado by 2030, according to the Colorado Health Institute’s (CHI) early analysis of the Senate’s healthcare bill. The State would also lose more than $15 billion in federal funding by 2030.

OTHER FEDERAL HEALTH REFORM NEWS:

Approximately 2.6 Million with Preexisting Conditions Gained Coverage Under the ACA

An estimated 2.6 million of the 16.5 million people who gained coverage between 2013 and 2015 have one or more preexisting health condition that would have allowed insurers to deny them coverage prior to the ACA’s consumer protections, according to a Commonwealth Fund brief. The authors note that the high-risk pools being proposed in Republican healthcare legislation would be insufficient to maintain these protections for people with preexisting conditions.

ACA Improved Affordability, Access and Self-Reported Health

The ACA’s coverage expansions reduced out-of-pocket medical spending, increased access to preventive services, improved adherence to prescription drugs, increased rates of treatment for chronic conditions, and improved self-reported health, according to a literature review published in the New England Journal of Medicine. The authors find mixed evidence on whether expanded coverage reduced mortality rates, noting that it may take more time for the effects of expanded coverage to impact mortality rates. 

Resource Highlights Counties at Risk of Having No Marketplace Insurer in 2018

A new map from the Kaiser Family Foundation identifies the 47 counties that may not have access to a Marketplace insurer in 2018, according to initial rate filings and media reports as of June 26; 33,894 individuals are currently enrolled in Marketplace coverage in those counties. The map will be updated as insurer participation in the Marketplace is finalized in fall 2017.  

Marketplace Insurers Announce 2018 Plans as Rate Filing Deadlines Pass

Oscar Health is expanding into three new states and will reenter the New Jersey market, while Anthem and Cigna announce new exits.

• Multiple States: Oscar Health announced plans to offer coverage in California, Ohio, and Tennessee for the first time, to reenter the New Jersey market after exiting in 2016, and to continue offering plans in New York and Texas.
• Colorado: All 2017 Marketplace insurers will remain on the State-based Marketplace in 2018, including Anthem, which is currently the only insurer in 14 rural counties. Twelve insurers in total have submitted 2018 rates to the State. 
• Indiana: Two more insurers are leaving the State’s Marketplace—Anthem and MDwise—both citing uncertainly at the federal level. Anthem currently has 46,000 Marketplace enrollees and MDwise has 30,000. Up to four counties in the State will have no Marketplace option in 2018. 
• Maryland: Cigna has exited the State-based Marketplace for 2018, citing “competitive developments” and “marketplace volatility.”
• Oklahoma: The State’s deputy insurance commissioner said that Blue Cross Blue Shield (BCBS), the State’s only Marketplace insurer, is planning to remain on the Marketplace in 2018. Though BCBS has not announced a final decision, they have submitted 2018 products and rates for the State’s review.
• Washington: All Washingtonians will have a Marketplace option in 2018 following discussions between State officials and health insurers. Two counties were previously at risk of having no Marketplace insurers.
• Wisconsin: Anthem will withdraw from the State’s Marketplace in 2018, citing market volatility and uncertainty around federal changes.

STATE MEDICAID REFORM ACTIVITY:

Michigan: State Moves Forward with Plans to Integrate Medicaid Physical and Mental Health Systems

The Department of Health and Human Services (DHHS) will begin implementing up to four two-year pilots to test the integration of physical and mental health services for Medicaid enrollees, with implementation beginning no later than March 2018. DHHS will be required to submit a report on pilot outcomes to the House and Senate HHS subcommittees.

Nevada: Governor Vetoes “Medicaid-for-All” Bill

Governor Brian Sandoval (R) vetoed a bill that would have allowed any State resident to purchase Medicaid coverage. Legislators are unlikely to attempt a veto override, though the bill’s sponsor, Assemblyman Michael Sprinkle (D), said he aims to reintroduce the legislation next session.

Ohio: State Senate Aims to Halt Medicaid Expansion Enrollment

The State budget passed by the Senate extends Medicaid expansion for one year but freezes expansion enrollment beginning July 1, 2018 and prohibits current expansion enrollees from re-enrolling if they leave the program. The Legislature will now reconcile different budgets proposed by the House and Senate, including determining the final policy on Medicaid expansion.

STATE STAFFING UPDATES:

Montana: Medicaid Director Stepping Down

Medicaid Director Mary Dalton announced her retirement after 30 years with the State Medicaid agency. Dalton played a “tremendous and influential role to improve healthcare access for Montana residents” and “leaves behind a legacy that will impact generations to come,” as noted in the release announcing her retirement.

Ohio: New Department of Health Director Named

Lance Himes was named director of the Department of Health. Himes has served as interim director since March of this year.

Washington: Governor Appoints Health Care Authority Interim Director

Governor Jay Inslee (D) appointed Louis McDermott to serve as interim director of the Washington State Health Care Authority (HCA), which oversees the State Medicaid program and the Public Employees Benefit Board program. McDermott replaces Dorothy Frost Teeter, who stepped down after four years leading HCA. McDermott was previously the director of the Public Employees Benefits Division within HCA.