Last night’s vote was about change, but what will Donald Trump’s presidency mean for healthcare benefits? The ACA will almost certainly change, although it is unclear if we will see full repeal or a major overhaul. With that said, Republicans won’t want to risk the backlash of kicking 25 million constituents off their plans. The task at hand is to “fix” the parts of the ACA that are ineffective. At this point, here’s what we think we know:
- The popular features of the ACA will likely remain, such as expanded eligibility for dependent children to age 26; the ban on pre-existing condition limits; and the closed gap in Medicare prescription coverage
- Repeal of the excise tax could become a reality -- but would a cap on the employee tax exclusion take its place?
- We’ll see a laser focus on how to create new, competitive markets for individuals who don’t get coverage through their employer or public programs, with Trump favoring individual tax preferences
Recent Mercer survey results found employers divided on repealing and replacing the ACA, with clear variation by employer size. While a majority of small employers favors repeal and replace (65% of those with 10-499 employees), that falls to just 36% of those with 20,000 or more employees. Our interpretation is that it is not the “repeal” as much as it is the “replace” that makes employer support uncertain. Given a Trump presidency and a Republican-controlled Congress, here are key issues for employers as they consider the impact on their health program strategies:
- Many employers welcome the promise of repeal of certain ACA requirements, especially the excise tax, the employer mandate, and reporting. But be prepared; it could take time -- a year or two -- for all the transitions to take place. These changes may need to be part of a larger plan for covering the 25 million uninsured who went to the public plans and Medicaid.
- Enrollment in high-deductible health plans continues to grow and there is keen interest in expansion of HSAs. Legislation has been proposed to increase funding limits and allow funds to be used for OTC medications, telemedicine visits, and onsite clinic visits to support further growth.
- While the rise of consumer-directed health plans has been an effective cost-management strategy, it has put financial pressure on employees and their families, so employers need to keep pushing for greater health care price transparency.
- Employers will also need to double down on Rx strategies. Republicans are less likely to go after pharma to control drug prices, and projections are for an additional $25B annually in new drug spend.
- More states passed time-off/sick leave laws. At the same time, employers are working on a proposal to get the federal government to pass ERISA-like safe harbor rules to ease the administrative burden of compliance with state and local laws.
Employers have done a great job of holding health benefit cost growth mostly below 4% in the years after the passage of the ACA, and 2016’s increase of just 2.4% was one of the lowest we’ve seen in decades. The threat of the excise tax was certainly a factor, and some employers made benefit cuts they didn’t want in order to hold down cost. To keep health care cost growth at sustainable levels in the years ahead will mean changing the health care system for the better, to ensure people get the right care, in the right place, at the right time -- and error-free.
Employers provide health care coverage for more than half of the American people and are uniquely positioned to be a driving force for meaningful change in how care is accessed and delivered. It is important that your voice is heard as the new policy debates begin. But don’t wait for the government. All of us must keep working to drive cost-effective care and better outcomes for our employees and their families.
Be careful what you wish for. Mercer has long been a member of the Alliance to Fight the 40, a group dedicated to convincing Congress to repeal the 40% excise tax on high-cost plans. Now, while the excise tax is likely to be thrown out along with many other parts of the Affordable Care Act, GOP lawmakers are contemplating capping employees’ tax exclusion for employer-sponsored health plan premiums – and many of the threshold numbers being bandied about are more onerous than the excise tax thresholds. Unlike the excise tax, which would be paid by employers or health plans, a cap on the exclusion would mean employees would pay income and payroll tax on the value of their health coverage that exceeds the threshold amount.
Mercer's Beth Umland and Moshe Radinsky pictured on Capitol Hill.
The Alliance to Fight the 40 arranged a “Hill Day” earlier last week – non-stop brief meetings with influential policymakers. Mercer’s healthcare reform leader Tracy Watts had drawn on various resources to assemble compelling data to support protecting the tax-favored status of employer coverage – the source of health insurance for 177 million Americans – and dispatched two of the contributors, Moshe Radinsky and myself, to make the case on Hill Day while she toured mid-western states briefing clients.
Shepherded expertly around the Hill (note to self: leave the heels home next time) by Washington Resource Group veteran Geoff Manville and Alliance colleagues, we attended six meetings with key staffers. Many of these folks seemed to be working around the clock to sketch out the long-awaited ACA replacement plan, which could wait no longer. There was a palpable sense that we were in the right place at the right time – staffers had a “need to know” and the meetings were brief but intense. Our message, in four bullets:
- Benefit richness is only one factor driving cost. A cost-based tax penalizes employers with older workers, more women, in high-cost health markets.
- Capping the tax exclusion at the levels being considered will affect more employers than the excise tax.
- Indexing the cap at CPI when health cost rises at several times CPI guarantees that eventually all employees will be taxed.
- Low-income families will see the biggest increase in effective tax rate under a cap.
The first look at a replacement plan was rolled out last week – by some of the groups we met with – and it did not include a cap. Insiders say it’s still to come. Meanwhile, we’re planning another trip.
Despite last week’s cold snap, the bloom of cherry blossoms along Washington DC’s Tidal Basin is now under way – a peaceful sight that belies this stormy moment in Congress, where new healthcare legislation is being debated and the headlines seem to shift from moment to moment. However, one thing is for sure: any legislation affecting the US healthcare system must consider the impact on employer-sponsored health insurance – the source of coverage for 177 million Americans, 16 times the number enrolled in public exchanges.
That’s why the leadership of MMC companies Mercer and Oliver Wyman created a health policy group to help formulate MMC’s views on ACA repeal-and-replace legislation. Our efforts led to the issue of a policy paper that showcased original Mercer research on changing the tax treatment of employer-sponsored coverage.
Last month, we took this research to the US House of Representatives to meet with policymakers actively working on the newly proposed American Health Care Act, or AHCA. We demonstrated that the excise tax on high-cost plans, currently law under the ACA, is not an effective method of penalizing rich “Cadillac” plans because plan design is only one factor affecting plan cost and often less important than location and employee demographics.
This would also be true of a cap on the employee individual tax exclusion for employer-provided health benefits, a provision included in an early draft of the AHCA and favored by powerful voices such as House Speaker Paul Ryan (R-WI), House Ways and Means Chair Kevin Brady (R-TX) and new HHS head Tom Price. Mercer had also modeled the impact such a cap would have on the effective tax rates of Americans based on their income. The hardest hit, by far, would be lower-paid workers with families. Some staffers faced with this information for the first time were visibly struck.
When the bill was released for mark-up, the cap on the exclusion was not included, and the Cadillac tax was delayed until 2025 (and possibly 2026). But while we were pleased with this outcome, we also knew the bill was a long way from becoming law and the cap could easily resurface.
It was my privilege to meet last week with Senators Rob Portman (R-OH) and Tom Carper (D-DE), both members of the Finance Committee; Senator John Cornyn (R-TX), Majority Whip and Member of the Finance Committee; and Senator Orrin Hatch (R-UT), Chairman of the Finance Committee. I urged them, first and foremost, to preserve the health benefit tax exclusion, and secondly, to liberalize HSA rules. I also discussed the potential impact of proposed cuts to the Medicaid program, and our concern that a surge in uncompensated care would cause providers to shift cost to private group plans – making it harder for employers to continue to provide adequate coverage to their workers.
Our work is far from done. I look forward to returning to Washington as the legislative debate continues – to advance the goal of preserving and enhancing the employer-sponsored healthcare system that is a stable source of good health coverage for approximately half of all Americans.
Join me on LinkedIn to continue the conversation. How will changes in healthcare policy have an impact on your organizations and people?
On Monday the CBO released its much-anticipated score of the American Health Care Act, the Republican legislation to repeal and replace the ACA. The CBO projection shows a loss in healthcare coverage for 24 million Americans over the next decade, accompanied by a reduction in the federal deficit of $337 billion. The state Medicaid programs are taking the biggest hit, with a decrease in funding of $880 billion during the same time period. In the short term, the CBO projects that health insurance premiums in the individual market will increase 15-20% and 14 million fewer Americans will have coverage as soon as next year.
None of this bodes well for employer-sponsored medical plans. At the time the CBO score was released, I was speaking at the Society for Human Resource Management's 2017 Employment Law & Legislative Conference. We asked the employers in the audience to respond to a polling question – “If healthcare reform were to occur this year, what are your concerns?” Overwhelmingly, the top concern was that a rise in the number of uninsured will lead to cost shifting by providers to employer-sponsored plans.
That was the theme of a recent article I co-authored with Terry Stone from Oliver Wyman. We argued that cost-shifting fails to address the underlying causes of cost growth – it may even worsen it. Moreover, increasing the cost burden on employers will simply make it harder for them to provide affordable coverage to the many millions of health consumers – 177 million, to be precise – who receive benefits through work. You can read more about our recommendations from health reform in this report.
On Monday evening, just as those of us on the East Coast were getting ready to call it a day, House Republicans unveiled the repeal and replace bill we’ve all been waiting for. While we haven’t finished our analysis yet, we have selected a few of the many articles on the bill for your perusal, including a long piece in the New York Times. One major headline: The bill didn’t include a cap on the tax exclusion for individuals covered in employer-sponsored plans, which was a welcome surprise since it had been included in an earlier leaked draft. But the unpopular Cadillac tax remains. The bill “repeals” the Cadillac tax only until 2025, which means it would still cast a shadow over employers’ long-term strategic planning.
Other big issues? The Medicaid expansion would be frozen in 2020 and then phased out, and Medicaid funding would be converted to block grants. This is a concern for employer health plan sponsors because of the likelihood that an increase in uncompensated care would result in cost-shifting to group plans by hospitals and other health care providers. How Medicaid is treated in the bill also looks to be the biggest potential roadblock to its passage: four GOP senators have already said they won’t sign on to changes in Medicaid funding that “could result in a reduction in access to life-saving health care services.” That would be enough to stop the bill if no Democratic senators vote to pass it.
Of course, the current bill is likely to change, especially since the Congressional Budget Office hasn’t yet scored the bill to determine any future impact on the deficit. “Mark-up” begins in the House on Wednesday. That’s the period during which lawmakers can amend the bill before putting it to a vote. We’re busy reading the bill ourselves and evaluating the impact it will have on employer-sponsored plans – where, as we keep reminding Congress, 177 million Americans are now covered.
This has been a busy week for healthcare in DC -- and the week’s not over yet! On the heels of the leaked Republican reconciliation bill language last Friday (that is already being described as out of date), the governors arrived over the weekend for a National Governors Association meeting that included dinner at the White House on Sunday. While the President tweeted that they “might” talk about healthcare, you can be sure the future of the Medicaid program and, more specifically, Medicaid funding, was at the top of the governors’ list of topics. Certainly, the 31 states that expanded Medicaid fear the funding implications of a block-grant program.
On Monday, the White House hosted a meeting with executives from the insurance companies to discuss government action required to "save" the failing individual market and convince (or perhaps, strong-arm) the carriers to stay in the game. Earlier this month, HHS announced revisions to the deadlines to file individual products to be offered in 2018 on the public exchange. This allows more time for legislative and regulatory action that might influence carrier decisions.
On Tuesday, the POTUS addressed the full Congress for the first time. He took a few minutes to lay out his five requirements for a replacement strategy. I’ll give you the short version below, but I recommend you also check out this Vox article, in which Sarah Kliff decodes the actual wording of each:
- Ensure Americans with preexisting conditions have access to coverage
- Help Americans purchase coverage through the use of tax credits and expanded health savings accounts
- Give states the resources and flexibility they need with Medicaid to make sure no one is left out
- Implement legal reforms to protect patients and doctors from unnecessary costs (presumably malpractice lawsuits) -- and bring down drug prices
- Allow the sale of health insurance across state lines
Meanwhile, it is widely reported that the Republican version of the reconciliation bill is changing constantly as various contributors attempt to balance the requirements of a very divided party -- all the while knowing that the Senate is working on its own replacement plan. We understand members of the House are reviewing the new bill and it is scheduled to go to committee for mark up next week.
Like I said, it’s been a busy week -- and there is no sign of the pace slowing anytime soon.
A leaked discussion draft of House Republican legislation to repeal and replace much of the Affordable Care Act (ACA) largely tracks earlier GOP proposals, including a cap on the employee tax exclusion for employer-provided health coverage. The February 10 draft includes the following proposals:
- Tax exclusion for employer-provided coverage capped. The draft would repeal the ACA's “Cadillac” tax now slated to begin in 2020. Instead, a cap would limit employees' federal income tax exclusion for the value of employer-provided coverage starting in 2020. (Employers would have additional payroll taxes if cost exceeds the cap.) Cost determinations for the cap would apply many of the same coverage inclusions and exclusions used for the Cadillac tax, but contributions to health savings accounts (HSAs) would not count. The cap is set at the 90th percentile of the employee and employer cost of group health coverage, as determined by the Department of Health and Human Services. The draft doesn't call for any cost adjustments for age, sex, or geography.
- Shared responsibility eliminated. Employer and individual shared-responsibility assessments would be effectively eliminated after 2015.
- Premium tax credits modified. Beginning in 2020, enrollees could get age-based premium tax credits ranging from $2,000 to $4,000 per year for individual coverage and unsubsidized COBRA. Individuals with access to employer coverage could not receive any tax credit.
- Employer's ACA reporting not addressed. The draft does not address ACA's current employer reporting responsibilities, so employers should plan to report for 2016. Beginning in 2020, health coverage providers would report on covered individuals and employers would report on premium costs to enable IRS administration of premium tax credits and the capped tax exclusion for employer coverage.
- ACA taxes repealed. ACA-related taxes would be repealed -- some at the end of 2016 and others in later years.
- Relaxed HSA limits and rules. Starting in 2018, permitted annual HSA contributions would increase to the maximum deductible/out-of-pocket limits for high-deductible health plans, and HSA rules would be eased in several respects.
- Medicaid expansion eliminated. Medicaid expansion would be repealed after 2019 and replaced with per capita Medicaid payments up to capped amounts.
These proposals will likely change before lawmakers introduce a bill, likely within weeks. In the meantime, Mercer will continue to advocate on behalf of our clients. Our recently released public policy point of view -- Health Reform and American Businesses: Critical Partner for Success -- demonstrates how important it is that the collective voice of employers be heard during the ACA ‘repeal and replace’ discussions and planning. You can make your voice heard through membership in plan sponsor and business groups or by contacting your congressional representatives in the House and Senate.
Almost immediately following the swearing in, President Trump signed his first executive order directing HHS, DOL, Treasury and other agencies within the government to waive, defer, grant exemptions from or delay provisions of the ACA that impose financial or regulatory burdens, to the extent allowed under the law. So what exactly is allowed? Here are the three main ways the administrative branch can exert influence over the ACA:
- Agencies can modify or revoke final rules through rulemaking process
- Agencies can decline to enforce (though not permanently ignore) statutes or final rules
- Proposed regulations can be ignored or revoked
Much has been written speculating about actions that will be taken under the executive order. The agencies could start to influence the individual mandate (by not enforcing penalties), subsidies (by seeking approval for temporary spending authority to reimburse insurance companies for plan design credits already paid), birth control coverage (making exemptions for religious non-profits) and Medicaid (allowing states more flexibility). However, the executive order should not affect the coverage of those currently enrolled in public exchange plans, since those plans are locked in for this year.
From an employer perspective, perhaps the biggest concern is the long term health and viability of the individual market. The ACA was designed to strike a delicate balance between requiring coverage to support a risk pool and insurance requirements to issue coverage, although that alignment has not been satisfactorily achieved thus far. Subsidies for health plans and the individual mandate are both “balancers” that were baked into the ACA, and removing or undermining them while the rest of the law remains in effect could have a negative impact on market stability. Market instability is bad for everyone, not just the individual market and those who rely on it.
Much has been written recently about President-Elect Trump’s nominee for Secretary of Health & Human Services, Rep. Tom Price (R-GA). A former orthopedic surgeon from suburban Atlanta, Price has served six terms in the House and is currently Chairman of the House Budget Committee. A recent article in The Washington Post reports Congressman Price "got into government to get government off his back."
He has been one of the strongest critics of the ACA and campaigned with Trump early on because Trump said he would repeal Obamacare. Price’s vision for health reform is laid out in legislation he introduced in 2015, the “Empowering Patients First Act.” Many of his proposals are similar to those outlined in House Republican leaders’ “Better Way” reform proposal.
Price would like to scale back much of the federal government's role in health care in favor of a free-market framework built on privatization, more flexibility for states, and tax code changes including a cap on the employee tax exclusion for employer-provided coverage. His vision includes repealing the ACA and reducing Medicare and Medicaid spending. These health entitlement cutbacks could have significant consequences for employers and corporate America by ultimately leading providers to shift more cost to private payers -- largely employer health plan sponsors.
As the Republican Congress moves to repeal and replace the ACA, Price will be a key player in negotiations with lawmakers, and the Center for Medicare & Medicaid Services (CMS) within HHS would actually set up and administer a replacement plan. In the meantime, there are some regulatory steps that HHS and other agencies could take to undermine the law, such as modifying or revoking final rules through the notice-and-comment rulemaking process. Agencies can also simply decline to enforce rules for a time.
Of particular interest to employers should be Price’s oversight of CMS’s Center of Medicare and Medicaid Innovation, which has supported experiments in health care payment reform such as encouraging a shift from fee-for-service to value-based models. Price in general does not support limiting physician discretion, which may put the fate of these programs in question.
Price’s nomination signals that big health policy changes are coming, though details and timing are in flux. We are closely monitoring developments with an eye to the impact on employers. Our intention is to help serve as a voice and advocate for the employer-sponsored health benefits system that provides coverage to 170 million American workers, retirees, and their families. As we formulate policy positions in support of that system, we will share them with the employer community and look forward to working together to meet the challenges and opportunities ahead.
IRS Notice 2016-70 extends the 2017 deadline from Jan. 31 to March 2 for employers and insurers to furnish individual statements on 2016 health coverage and full-time employee status (Forms 1095-B and 1095-C). The notice also extends 2015 penalty relief to 2016 incorrect or incomplete reports due in 2017 if the preparer has made good-faith efforts to comply. The extension does not change the Feb. 28 (paper) and March 31 (electronic) IRS filing deadlines.
With the election behind us, the news is full of speculation about what will happen next. We hosted a webcast for employers two days after the election and had a record turnout, taking the opportunity to conduct a quick opinion poll about repealing and replacing the ACA and other possible legislative actions by the new president and the 115th Congress.
Employers have strongly supported repealing the excise tax and the employer mandate since they were first enacted. In our poll last week, 63% of the more than 650 employers participating said they favored repeal-and-replace of the ACA; only 15% said they oppose; and 22% said they don't have an opinion yet. Admittedly, we don't have any real details on what repeal looks like, so this response can be interpreted as interest in something different from what is currently in place.
We also asked respondents how much of a priority they would like to see the new administration place on some issues of concern to employers. Here are the top three:
- Prescription drug cost and price transparency was considered the highest priority of the issues, with a rating of 4.3 (using a scale of 1-5). As we mentioned in an earlier post, a Kaiser Family Foundation survey found that prescription drug costs were the Number One health care issue for voters, ahead of Obamacare. Rising drug costs are currently one of the biggest drivers of employer health plan cost. With 40 new high-cost specialty drugs projected to hit the market each year for the next five years, it is easy to see why this tops the list.
- HSA expansion was the second priority, with a rating of 3.6. Implementation of high-deductible health plans has accelerated in recent years, and enrollment reached 29% of all covered employees in 2016. Employers support changes that would make these plans more attractive to employees, such as higher annual contribution limits and allowing funds to be used for OTC drugs and telemedicine visits.
- A national uniform paid leave framework was the third priority (3.3). With 42 different paid leave laws now on the books (in seven states and 34 municipalities), employers with operations spanning many locations face huge compliance and administrative challenges and many would welcome relief.
While this list is by no means everything being discussed in Washington related to health and group benefits, it is representative of some of the top issues for employers. With change in the air, you have an opportunity to influence the debate. Now is an especially important time for employers to make their voices heard in the policy debate, either independently or as part of several organizations such as the American Benefits Council, the ERISA Industry Committee, the National Business Group on Health, and the US Chamber of Commerce, to name just a few. Your congressional representatives and the incoming Trump administration need and want to hear from you!
Just a few days after the dramatic collapse of efforts to pass the House GOP’s American Health Care Act, more than 1,300 folks with an interest in employer-sponsored health benefits joined a Mercer webcast* to learn a) what the heck just happened, b) now what, and c) what does this mean for employer health benefits? A team from our Washington Resource Group aced the first question and gave as good a look into the future as possible without a crystal ball.
We took advantage of the opportunity to ask the health benefit professionals on the call a couple of questions, starting with their reaction to the (apparent) death of the bill. More respondents were relieved than disappointed; in fact it wasn’t even close. Enough said.
Our second question was inspired by our belief that while shoring up the individual market and ensuring Americans have access to affordable health coverage is critical, neither the AHCA nor the ACA did nearly enough to address the underlying problem in the US healthcare system: too much cost for not enough value. Given that employers provide coverage to more than half of all Americans, employers are key stakeholders in any effort to reform US healthcare. So what would they like Congress and the administration to prioritize going forward?
At the top of the wish list is help with controlling the escalating cost of pharmaceuticals: on a scale of 1-5, that scored a 4.4. Next was improving price transparency for all medical services and supplies. Most respondents to the poll also want the government to maintain Medicaid funding and stabilize the individual market so that people not in employer-sponsored plans have access to affordable coverage. A rise in the number of uninsured will increase providers’ risk for uncompensated care, leading them to hike rates for private payers. This type of cost shifting does nothing to address the underlying cost of care and makes it harder for employers to provide affordable coverage.
As we’ve been saying, employers are uniquely positioned to help control healthcare spending and promote positive health outcomes. They are working to help employees become responsible insurance consumers and are a trusted source of health information and resources. Policymakers should view this health reform “reboot” as an opportunity to partner with American businesses to drive higher quality, lower costs, and better outcomes for all Americans.
*Mercer Select Intelligence membership required. Not a member? Learn more