After their failed attempt to pass ACA repeal and replace legislation, President Trump and House Speaker Ryan indicated that they were “moving on” to other legislative priorities. On Tuesday, we learned that Republicans have restarted their conversations about healthcare. On Wednesday, Bloomberg reported the GOP was discussing a new vote as early as next week.
At Mercer, we believe that the current healthcare system is unsustainable, but we urge that changes be made without undue haste and with careful consideration of the many complex factors at play in our system. We are actively advocating for new health savings account rules and the repeal of the Cadillac tax and, as I said in my blog post earlier this week, we stand ready to support lawmakers in shaping policies that will address the underlying causes of healthcare cost growth.
Our conversations with employers across the country echo these priorities. For instance, the morning of the day the bill was pulled, I gave a speech at the North Carolina Business Group on Health annual conference. I asked the group of benefits professionals if they could ask one wish of the President and Congress, what would it be? Responses included:
- Healthcare coverage for all
- Consideration of the consequences of cutting federal funding for Medicaid and public health programs
- Consideration of the consequences of cost-shifting to older pre-Medicare-eligible Americans
- Help addressing unnecessary/inappropriate care, ER visits, and opiate use
- Help with escalating prescription drug costs
- Relief on the ACA reporting requirements
What would your "one wish" be?
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.
Before the ACA, many self-employed individuals found it challenging to find a health plan on the individual market that met their needs, let alone to pay for it. Post ACA, the ability to obtain affordable coverage not tied to an employer has givenentrepreneurs in the growing ‘gig’ economy the flexibility to pursue their goals without having to worry about maintaining health coverage. These days may be coming to an end if the new GOP health care bill passes, however. Under theAmerican Health Care Act or AHCA, subsidies are dependent on age, as opposed to income (like under the ACA), and are not adjusted for geography, even though health costs vary widely depending on where you live. This could mean big changes in the amount of assistance an individual would receive under the AHCA compared to under the ACA. As cited in the article, a 40 year-old in San Francisco making $30,000 a year would receive $800 less a year under the new plan, and a 40 year-old living in Santa Cruz County, CA would see a $2,490 less per year -- potentially putting coverage out of reach.
A study published by the McKinsey Global Institute estimates that U.S. has between 54 million and 68 million ‘independent workers’, with some working independently full-time and others using independent/freelance work to supplement their primary income. With the proposed changes under the AHCA, some individuals may try to seek traditional employment for the purpose of healthcare coverage, or they may just choose to go without coverage completely. While critics of ACA subsidies have said they discourage people from seeking employment or advancing their careers since an increase in income would result in a decrease in subsidies, this new plan could have the same discouraging impact on the next generation of entrepreneurs.
In an effort to garner more support for their ACA repeal legislation, House Republican leaders revealed changes to the legislation on Monday night pending the Rules Committee vote before going to the House for their vote. Of greatest interest to employer plan sponsors is the delay in the Cadillac Tax from 2025 to 2026. The bill’s amendment repeals some of the other ACA taxes retroactively to the beginning of 2017 instead of 2018 as originally proposed. Other changes include additional funding to increase tax credits for older Americans and some Medicaid revisions.
In light of the changes, the House Freedom Caucus has indicated they won’t oppose the legislation, but they may still have enough “no” votes to kill the bill. President Trump went to the Hill on Tuesday to help the House Leaders secure support for the bill. In the meantime, the CBO is analyzing the changes and is expected to issue a new CBO score before Thursday’s House vote. The Brookings Institution doesn’t expect a meaningful improvement in the score.
This article discusses the tax conundrum Republicans are facing as they try to repeal portions of the ACA. In short, legislation passed through reconciliation cannot increase the deficit beyond the budget window. With the proposed repeal of most of the ACA taxes, Republicans are using the Cadillac Tax to “smooth over the budget math.” The Cadillac Tax is disliked on both sides of the aisle so there’s still hope for a full repeal before the 2025 effective date. In the meantime, employer groups like the Alliance to Fight the 40, American Benefits Council, and ERIC continue to oppose the tax.
Employers recognize the important role of healthy communities in employee well-being. The government plays an important role in creating healthier communities through the support and funding of public health initiatives. That’s why we found The American Health Care Act’s repeal of the Prevention and Public Health Fund concerning. The fund provides money to the CDC to support disease prevention programs. The loss of funding is likely to impact:
- The federal vaccines program which ensures healthcare providers receive the vaccination doses they need and mobilizes responses to disease outbreaks.
- Public health programs aimed at preventing and reducing the risk of heart disease.
- Programs to reduce the risk of healthcare-associated infections. One-hundred percent of the money the CDC uses for this effort comes from this fund established under the ACA.
Prevention and public health funding addresses community health, and communities are where employees live. Well-being is linked to improved productivity, absenteeism, presenteeism and healthcare utilization – all factors that can impact a business's bottom line. For individuals, health and well-being affects both financial security and quality of life.
Just FYI. Since the ACA was enacted, there has been a succession of repeal and replace proposals coming out of Washington, culminating in this week’s House Republican bill. The Kaiser Family Foundation makes it easier to compare and contrast the proposed changes to specific ACA provisions with an interactive tool posted on their website. Click on a provision, for example, “Premium subsidies for individual,” to see how subsidies are currently handled under the ACA and how that changes in the proposed American Health Care Act. Take it a click further to see this same provision in any of five other proposals, including HHS leader Tom Price’s “Empower Patients First” Act from 2015. Given predictions that the AHCA will have a tough time getting to the President’s desk as currently written, you may want to bookmark this page.
Well, now we know. A week ago, House GOP leaders presented an outline of an ACA repeal and replace plan with a key element missing – the source of revenue to fund the tax credits that would replace subsidies to assist people buying individual insurance. Today, Politico reported that in a leaked draft of ACA repeal-and-replace legislation, GOP lawmakers are proposing to do away with all ACA taxes, including the Cadillac tax. The only source of revenue in the bill is a cap on the income tax exclusion for people receiving health benefits through an employer plan. This differs from the Cadillac tax in that it hits plan members directly, rather than the employer or the plan. The draft bill sets the threshold at relatively high levels, but it is easy to speculate that the threshold could come down if this provision alone must pay for the replace plan.
Of course, this is only a draft – a leaked draft at that – and our lawyers have only just begun reviewing it. But our earlier analyses have shown that under any cap scenario, lower-income people will see the biggest increase in their effective tax rate. Another concern is that, if the goal of the tax is to penalize the most generous plans, basing the cap on premium cost means that plans with older workers and more women, and those located in high-cost areas of the country, will be likely to trigger the tax, since these factor all influence cost as much or more than plan design.
Give the Politico article a read, and if you’re concerned about the effect of a cap on your employee population, now would be a good time to let your representatives know.
Mercer hosts a monthly Washington Update webcast, and as you'd imagine, attendance varies based on the current activity in Washington. No surprise to find a large crowd calling in yesterday to hear the latest news. Employee Benefit News shared the highlights in an article. We could see the ACA replacement plan as early as next week. Specific details are still unknown and when announced will likely be modified as the legislative process begins. Stay tuned – more to come.
Rep. Tom Price (R-GA) was confirmed early Friday morning as Health and Human Services Secretary in a 52-47 vote down party lines. The vote comes at the end of a contentious confirmation process, which raised questions from Democrats about his healthcare stocks, his plans for Medicare, and his opposition to the ACA. President Trump said last month that he would file a plan to repeal and replace the ACA “as soon as the Secretary is approved,” but has more recently indicated that a replacement plan could take until next year. Many are now looking to Tom Price’s confirmation for clues about the new administration’s commitment to an ACA repeal-and-replace timetable. According to this Wall Street Journal article, Price is “expected to follow through on an executive order, issued by Mr. Trump on the first day of his administration, directing federal agencies to pare back regulatory elements of the ACA.” The article also speculates that he could overturn the mandate that health plans include contraceptive coverage at no cost to the patient, “a protection that isn’t explicitly written into the law.” More to come on this – we’ll be watching Price’s first days closely.
The path Congress will take to repeal and replace the ACA has been anything but clear. Since the election, many approaches have been discussed, some that could take up to two years to implement. Trump is asking Congress to move more quickly. Last week, a committee of House Republicans released four bills that suggest a new direction. In an article in Health Affairs, author Timothy Jost says “…they are not aimed at destroying the ACA, but rather at trying to calm insurers and a nervous public. Some may even pass on a bipartisan basis. This is a very interesting development.”
Each bill is focused on a different piece of a replace strategy, addressing areas that seem to be creating the highest levels of angst. The first three are aimed at insurance company concerns in hopes of stabilizing the individual insurance market:
verification of eligibility to enroll and receive a government subsidy
expand the age category ratios for insurance company pricing
tighten the grace period for non-payment of insurance premiums
The fourth bill affirms a commitment to continuing to ban pre-existing condition limits, an issue that has captured the attention of members of both individual and group health plans.
These bills are to be the topic of a House Energy and Commerce hearing on Feb 2, which is a first step in the vetting process. While these bills do not directly address employer concerns, movement to stabilize the individual market sooner rather than later is a welcome response that will benefit individual and group health plans alike.
Since the Presidential election, many have commented on expected legal and regulatory changes. One of them being prescription drug pricing. It seems that Republicans and Democrats can all agree on the need for more transparency into the cost of drugs. As far as doing something to lower the cost, initially it seemed that with Republicans dominating both Congress and the White House, we might not see much action in this area. But Trump made it clear in his press conference yesterday that he plans to go after drug costs. While no specific plan has been announced, relief for rising drug costs would be welcomed by employers -- provided that pressure applied on Medicare drug costs does not mean cost shifting to private payers. We are keeping close tabs on this issue.