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October 18, 2017

What's inside the bipartisan ACA deal

Daily Briefing

    Sens. Lamar Alexander (R-Tenn.) and Patty Murray (D-Wash.) on Tuesday unveiled a short-term, bipartisan proposal to bloster the Affordable Care Act's (ACA) exchanges—though it remains to be seen whether the bill will get enough support to pass in the House and Senate.

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    The deal caps off an effort that Alexander, who chairs the Senate Health, Education, Labor, and Pensions (HELP) Committee, and Murray, the committee's ranking Democrat, began in September after GOP senators failed to pass a bill to repeal and replace the ACA.

    What's inside the proposal

    According to the Wall Street Journal, the proposal "could potentially affect many of the roughly 18 million people in the individual market as well as employer coverage in some states."

    Funding for cost-sharing reduction payments

    The proposal would appropriate funding for the cost-sharing reduction payments Trump halted last week for the remainder of 2017, as well as for 2018 and 2019.

    According to Axios, the proposal would require state insurance regulators to ensure that plans receiving CSR payments in 2018 pass the funding on to low-income enrollees or the federal government. Axios reports the language is intended to prevent insurers that previously assumed CSR payments would be cut off from "double-dipping" by maintaining higher premium rates while also receiving the CSR payments.

    Expanded flexibility under ACA's 1332 waiver process

    The proposal also would increase flexibility in the ACA's so-called state innovation waivers, including an expedited waiver approval process and longer waiver duration.

    According to CQ News, a one-page summary of the bill suggested that states might approve higher copayments for opioids or lower copayments for statins. The summary also cited Iowa's waiver application, which seeks to redesign its exchange and change funding for patients with higher medical bills.

    According to Politico, the draft bill also would change some of the ACA's guardrails for the waiver program. Instead of requiring state innovation plans to be "as affordable as" existing ACA coverage, the HHS secretary could approve plans "of comparable affordability" to current plans.

    Alexander said the proposal would not change the ACA's requirements on health benefits or allow insurers to charge individuals with pre-existing conditions more for coverage.

    Other changes

    The proposal also would:

    • Allocate $106 million for open enrollment outreach for 2018 and 2019;
    • Allow certain high-risk pools; and
    • Expand eligibility for catastrophic health plans, which under the ACA are limited to individuals under age 30 or those experiencing financial hardships, to all consumers regardless of age or income.

    Path forward uncertain

    It remains to be seen whether the Alexander-Murray proposal will have enough support to pass Congress.

    Conservative Republicans greeted the announced bill with mixed reactions. Rep. Mark Walker (R-N.C.), who leads the conservative Republican Study Committee, said, "The GOP should focus on repealing & replacing Obamacare, not trying to save it. This bailout is unacceptable." However, Rep. Mark Meadows (R-N.C.), who chairs the conservative House Freedom Caucus, described the agreement as a "good start."

    A bipartisan group of 23 House Republicans and 23 House Democrats also praised the agreement on Tuesday, saying, "It aligns closely with our framework and we look forward to working closely with Congress and the White House to pass bipartisan legislation."

    Trump's opinion on the proposal is unclear. On Tuesday, he appeared to support it, saying, "It is a short-term solution so we don't have this very dangerous little period." But on Wednesday, Trump in a tweet said, "I can never support bailing out ins co's who have made a fortune w/ O'Care."

    According to Axios' "Vitals," neither House Speaker Paul Ryan (R-Wis.) nor Senate Majority Leader Mitch McConnell (R-Ky.) have indicated whether they would hold votes on a final bill. However, on Wednesday, Ryan spokesperson Doug Andres, said, "The speaker does not see anything that changes his view that the Senate should keep its focus on repeal and replace of Obamacare."

    Reaction from health providers

    Federation of American Hospitals President and CEO Chip Kahn in a release called on "both the House and Senate to act swiftly on this important legislation since enrollment begins in a matter of days." He said, "Ensuring that federal funds remain available to pay for the subsidization of the cost sharing is vital to keeping premiums in check and coverage available to so many people that depend on this critical program."

    Kaiser Permanente Chair and CEO Bernard Tyson in a tweet said he was "encouraged" by the deal, adding, "I remain optimistic we can make progress on increasing access for Americans to high-quality, affordable care. Today is a good start" (Kaplan/Pear, New York Times, 10/17; Haberkorn, Politico, 10/17; Scott, Vox, 10/17; Owens, Axios, 10/18; AP/STAT News, 10/17; Baker, "Vitals," Axios, 10/18; Armour/Peterson, Wall Street Journal, 10/18; McIntire, CQ News, 10/17 [subscription required]; Cowan, Reuters, 10/18).

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