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One possible fix for the public exchanges? Repeal the ACA provision expanding dependent coverage.  Allowing young adults up to age 26 to be covered under their parents’ plans has been one of the law’s most popular provisions, especially since it went into effect at a time when many young people were struggling to find full-time work in the wake of the recession. But it also took these same people out of the potential pool of enrollees when the exchanges opened in 2013. While many factors have contributed to premium spikes in exchange coverage in some states, one quoted across the board has been that fewer young people than expected signed up for coverage. Had young adults not been able get coverage through their parents’ plans, it’s possible a portion of them would have signed up for exchange coverage. And having these younger, and generally healthier (i.e., lower risk) individuals in the pool might have helped to keep the premiums down. 

 

Leading up to Thursday’s vote in the House on the AHCA, the GOP’s repeal and replace bill, lowering the dependent eligibility age to 23 was on the list of possible amendments but then withdrawn. As acknowledged in thisPolitico article, repealing the provision would be political suicide for anyone that proposes it; people don’t react well to losing a benefit they’ve gotten used to having. Yet the upsides for removing this provision are, in principle, aligned with GOP repeal and replace goals, namely, removing additional costs imposed through the ACA and helping to stabilize the individual market.

 

One approach might be to phase out this provision, or grandfather individuals born before a certain date, so that families have time to prepare and plan for alternative coverage for their older children. Of course, this only works if there’s an affordable health care option for these young adults on the exchanges. If the current subsidies are reduced to the levels proposed under the AHCA (an individual under 30 would only receive $2,000 towards health coverage per year regardless of income or location beginning in 2020), then leaving these individuals to the mercy of the individual market may not be wise; it could create a “black hole” of coverage from age 26 perhaps until the age when people are starting their families and see an absolute need for care.  So while employers as well as the individual market could benefit from a rollback of this provision, adequate subsidies on the exchanges would need to be in place to help these individuals purchase and maintain continuous coverage.

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While I spend most of my work days helping large employers with their health benefit programs, this past week I wore my Mercer health reform leader hat at my own personal version of health policy summer camp in Washington. I spent two days with the American Benefits Council’s policy board, took some meetings on Capitol Hill, and visited with Julie Rovner and Julie Appleby at KAISER Health News. 

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Earlier this week, we hosted a Mercer Select Briefing and asked participants to ponder changes they might make to their health benefits if the ACA’s employer mandate were fully or partially repealed. Of the 175 employers taking the poll, relatively few anticipate making any particular change. The largest number of respondents – 21% – said they would be likely to set higher employee contributions for individual coverage than currently permitted under the affordability requirement. Given that many employers have added lower-cost plans since the ACA was signed, most don’t have an issue with affordable contributions. Just 19% said they would be likely to resume a 40-hour work-week requirement for eligibility (rather than the 30-hour requirement under the ACA) and the same percentage said they would likely revisit lifetime benefit dollar limits. Fewer than one in ten employers thought they might impose pre-existing condition limitations, and almost none said they were likely to require more than a 90-day waiting period for benefits. 

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The anxiously awaited CBO score of the AHCA – reflecting the last round of changes made to the bill before it was passed – was released yesterday afternoon. The nonpartisan scorekeeping office forecast the AHCA would cut the federal deficit by $119 billion over the next 10 years, down from $150 billion in the prior score. From a process perspective, the bill still easily passed the test to save at least $2 billion to qualify for consideration under a reconciliation process that is filibuster-proof by requiring only 51 votes in the Senate, not the typical 60-vote threshold.

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Many Americans and employers agree that a top priority for President Trump and Congress should be lowering prescription drug costs. That was underscored this week with introduction of bipartisan legislation – the Fair Drug Pricing Act – a step in the direction of greater price transparency. The bill would require drug makers to justify their pricing and itemize their expenses before raising prices more than 10% in one year, or 25% over three years, on drugs that cost at least $100. (Remember the EpiPen controversy from last year?) Shortly after receipt of this pricing information, HHS would be required to make the data publicly available. In addition to providing a check on sharp price hikes, this could help PBMs and other drug purchasers make more informed decisions.

 

The Fair Drug Pricing Act mimics bills that have been introduced in more than a dozen state legislatures, and a growing number of state and federal lawmakers have offered a variety of proposals to address the issue. Congressional Democrats, for example, have proposed to allow Medicare to negotiate prices, remove tax breaks drug makers receive for advertising expenses, speed generic drugs to market, and allow Americans to import medicines from Canada, among other things.

 

The pharmaceutical industry opposes and will fight most of the proposals, but it’s clear that the industry and policymakers are feeling the heat over drug prices.

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While working women continue to earn less money than their male counterparts, the gap is narrowing when it comes to health benefits. Three years ago, we used data from Mercer’s National Survey of Employer-Sponsored Health Plans to examine the difference in benefits between large employers with workforces that are 65% female or more to those with workforces that are 65% male or more. Just under half of the mostly female companies are in health care and a quarter are in the services sector, while mostly male companies are found predominately in the manufacturing industry (52%). The percentage of employees in collective bargaining agreements has remained about the same for the two groups (13% for companies with mostly female employees and 15% for companies with mostly male employees). One workforce statistic has seen some movement since 2013, when the average salary for mostly female companies was about $10,000 less than when the workforce is mostly male; data from our 2016 survey shows the difference is now over $15,000. That’s right – the gap in the average salaries of companies with mostly female vs. mostly male workers has only gotten wider.

 

The health benefits at organizations with predominantly female workforces continue to be less generous than in those with predominantly male workforces. In addition, the employee contributions for these less generous plans are higher than those for the richer benefits offered to employees at mostly male companies. For coverage in a PPO, the most common type of medical plan, the monthly contribution for family coverage is 17% higher ($484 for mostly female companies and $415 for mostly male companies), which is down from a 31% difference in 2013.

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Republican senators will continue discussions this week on revisions to legislation narrowly approved by the House -– the American Health Care Act – to repeal and replace much of the Affordable Care Act (ACA). Passing a bill out of the Senate may be an even tougher fight for Republicans, who can’t afford more than two defections.

 

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Earlier this week we learned that the CBO will release their “score” of the AHCA the week of May 22. This revised projection will reflect the most recent changes to the bill – allowing states to opt-out of certain provisions including essential health benefits, aspects of community rating and changes to age banding ratios as well as $8 billion in funding to help states that choose to waive the ACA's community rating for individuals who don't have continuous coverage.

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With all the uncertainties around healthcare legislation swirling, cost control of pharmacy spend remains top priority for employers. On one hand, employers obviously want their employees to have access to the medications they need: drugs like insulin, blood pressure treatments, and cholesterol blockers have long played a critical role in employees’ health. But now new specialty biotech drugs – some of them true medical breakthroughs – are flooding into the market, at costs much higher than previous therapies. Drug prices spiked by 9.8% between May 2015 and May 2016, and there are more sharp increases ahead. Drug costs are quickly becoming unsustainable, for both employers and, increasingly, plan members. Many high-cost brand name drugs may have rebates to reduce their net cost, but the member or patient typically does not see these rebates so their out-of-pocket cost is still high. And even the cost of some generic drugs has risen dramatically.

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The vote to pass the AHCA in the House – a first step on the road to repealing the ACA – has raised questions about how employers might respond if the ACA requirements affecting employer-sponsored plans were to be lifted. One way to approach that question is to look at how employer plans changed – and how they didn’t change – under the ACA. We went back to past Mercer National Survey of Employer-Sponsored Health Plans databases to find out.

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Well, it happened. House Republicans got the votes to send the AHCA on to the Senate. The bill will face tough challenges in the Senate, so this is far from a done deal. For now, it is business as usual under the ACA.

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Check out this article for tips on managing out-of-pocket expenses in a high-deductible health plan. Typically, your paycheck deductions are lower, which is a bonus, but how do you keep from falling behind financially when you need care? Here are the author’s suggestions, plus a few from me.

  • Take advantage of preventive services covered at 100%. For example, get a flu shot so you are less likely to get sick.
  • Use in-network providers for the lowest possible out-of-pocket expense.
  • Consult with a nurse for free by calling the nurse-line for a consultation before scheduling an appointment with a physician; it could save you the cost of an office visit
  • Many plans include a telemedicine benefit. The cost of a telemedicine visit is usually around $40-$50, and can be scheduled at your convenience via phone or video chat.
  • Investigate "convenience care” clinics in your area. Located in stores like Target, CVS, and Walgreens, they offer a limited number of services at a lower cost than urgent care or a physician office visit.  
  • When your doctor recommends a prescription drug, ask how much it costs and if there is an over-the-counter or generic option. Check a few different pharmacies for the best price. 
  • If a prescribed drug is very expensive and you have not used it before, ask whether you could have a smaller number of pills at first to be sure it works. Check to see if there are patient assistance programs to help defray the cost.
  • Shop around for services and tests. A variety of tools exist to support comparison shopping; check with your insurance company for help.
  • Some employers offer indemnity coverage -- policies that will pay a set dollar amount when you have an accident or are hospitalized. These low-cost coverages can provide peace of mind for those concerned about covering expenses before they meet their health plan’s high deductible.
  • If you’ve moved to the high-deductible plan from a more expensive plan, take the savings from lower paycheck deductions and deposit them (tax-free!) in a health savings account. That way you will have some money set aside to help pay for care before you meet the deductible. Many employers will help fund your HSA.  
  • Take advantage of any opportunities to earn dollars for your HSA by participating in healthy activities like biometric screenings. 

These are good suggestions to communicate to employees and their families. Even if you have provided similar guidance in the past, everyone can always use a refresher.

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House Republican leaders are working to win the votes needed to pass a revised version of their health care reform bill, the American Health Care Act (AHCA), that aims to lower health insurance premiums for some individuals by letting states obtain waivers to opt out of the Affordable Care Act's (ACA) essential health benefits, community rating, and age banding requirements.

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