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One of the core functions of health insurance is to protect people against financial ruin and ensure that they get the care they need if they get seriously ill. To help ensure that insurance plans met that standard, the Affordable Care Act (ACA) required plans to limit enrollees’ annual out-of-pocket spending and barred plans from placing annual or lifetime limits on the total amount of care they would cover.

These protections against catastrophic costs apply to almost all private insurance plans, including the plans held by the roughly 156 million people who get their coverage through an employer. A provision added Thursday night to American Health Care Act (AHCA), the health care legislation currently being debated in the House of Representatives, could jeopardize those protections—not just for people with individual market plans, but also for those with employer coverage.


Specifically, the Thursday’s manager’s amendment would modify the “essential health benefit” standards that govern what types of services must be covered by individual and small group market insurance plans. The intent of the amendment is reportedly to eliminate the federal benefit standards that currently exist and instead allow each state to define its own list of essential health benefits. While some have suggested that the drafting of the amendment makes its actual impact unclear, this blog post examines the consequences if the amendment achieved its reported intent.


Much analysis of potential changes to essential health benefits has focused on the potentially severe consequences that could befall a state’s individual health insurance market in the absence of effective essential health benefit requirements. However, weakening essential health benefit standards could also have important negative consequences for the coverage offered by employers of all sizes because it would weaken the ACA’s guarantee of protection against catastrophic costs. That is because the ACA’s ban on annual and lifetime limits and its requirement that plans limit enrollees’ annual out-of-pocket spending only apply to spending on essential health benefits. Thus, as the definition of essential health benefits narrows, the scope of the ACA’s guarantee of protection against catastrophic costs shrinks as well. In the absence of any essential health benefit standards at all, these protections would effectively disappear because they would apply to an empty set of health benefits.

In practice, the House proposal appears likely to seriously weaken the definition of essential health benefits and thereby seriously weaken the ACA’s guarantee of protection against catastrophic costs
​

In practice, the House proposal appears likely to seriously weaken the definition of essential health benefits and thereby seriously weaken the ACA’s guarantee of protection against catastrophic costs. In light of the patterns of state benefit regulation that existed prior to the ACA, it appears plausible that many states will set essential health benefit standards that are considerably laxer than those that are in place under the ACA. In addition, large employers may have the option to pick which state’s essential health benefits requirements they wish to abide by for the purposes of these provisions; this would likely have the effect of virtually eliminating the catastrophic protections with respect to large employers since employers could choose to pick whichever state set the laxest standards. The same outcome would be likely to occur for all private insurance policies if insurers were permitted to sell plans across state lines, as the Administration has suggested enacting through separate legislation.


The remainder of this blog post discusses these issues in greater detail.


The Affordable Care Act’s Protections Against Catastrophic Health Care Costs


Health care spending varies widely across individuals. While most of the population faces relatively moderate health costs in any particular year, a minority of the population is seriously ill and faces very large expenses. For example, people in the top one percent of health care spending in 2014 incurred expenses exceeding $100,000 in that year. One of the core purposes of health insurance is to cover those catastrophic expenses, thereby ensuring that seriously ill people can access these services continuing to meet their other financial needs. That protection is financed through the premiums paid by those lucky enough to remain healthy.


The ACA introduced a pair of reforms to help ensure that private insurance plans provided this type of protection against catastrophic costs. Both had significant impacts on plan designs, not just in the individual health insurance market, but also in employer coverage. The first of these reforms was a requirement that plans limit enrollees’ annual out-of-pocket spending on essential health benefits. This provision took effect in 2014 and applies to almost all private insurance policies, whether offered on the individual market or through an employer.[SUP][1][/SUP] For 2017, the out-of-pocket maximum can be no more than $7,150 for single coverage and no more than $14,300 for family coverage.


Since the ACA became law, the share of people in employer-based single coverage whose plans lack a limit on out-of-pocket spending has fallen precipitously, from 18 percent in 2010 to just 2 percent in 2016, according to the Kaiser Family Foundation and Health Research and Education Trust’s Employer Health Benefits Survey. The sharp decline in 2014 is likely primarily attributable to the new requirement, and much of the pre-2014 decline likely reflects efforts by insurers and employers to prepare for the beginning of the requirement in 2014. On the basis of these data, the Council of Economic Advisers estimated in December that 22 million more people with employer coverage had out-of-pocket limits in 2016 than if the prevalence of out-of-pocket limits had stayed at its 2010 level.[SUP][2]

[/SUP]
es_20170324_ooplimitchart.png


The second set of reforms was a bar on insurers imposing annual or lifetime limits on the amount of essential health benefits they cover. This provision also applied to almost all private insurance plans.[SUP][3][/SUP] Such limits were typically set at relatively high levels, so the probability of reaching those limits was very small. However, people who were unlucky enough to do so faced financial ruin.


My Brookings colleagues Loren Adler and Paul Ginsburg recently reviewed evidence on the prevalence of lifetime limits in employer coverage before enactment of the ACA. A majority of employer plans appears to have included such limits, with data from the Employer Health Benefits Survey indicating that 59 percent of enrollees in employer coverage were in plans that featured a lifetime limit in 2009. Using these data, Adler and Ginsburg estimated that 109 million people with private health insurance would have a lifetime limit today without this provision of the ACA. Their analysis also provides estimates of the number of people who would have lifetime limits in each state today but for that provision.


Data on the prevalence of annual limits is more limited. However, in regulations implementing the ACA’s annual limit requirements, the Departments of Treasury, Health and Human Services, and Labor reported estimates from a survey by the benefits consultancy firm Mercer. That survey found that around 8 percent of individuals enrolled in plans offered by large employers had annual limits, and around 14 percent of individuals enrolled in plans offered by smaller employer had annual limits.


The Link Between the ACA’s Protections Against Catastrophic Costs and Essential Health Benefits


It may seem surprising that changes to essential health benefits could have important effects on plans offered by employers, particularly large employers. Indeed, the most prominent function of the essential health benefits standards is to define what services individual and small group policies must cover. That role is particularly important in the individual health insurance market. As many analysts have noted, without those requirements, insurers would likely decline to cover categories of care needed by sicker enrollees (or charge a very high premium for such coverage). As a result, the only available plans would either offer very skimpy coverage or have very high premiums.


However, the essential health benefits standards also play an important role in defining the scope of the ACA’s protections against catastrophic costs. Specifically, the out-of-pocket limit requirement applies only to cost sharing “with respect to essential health benefits covered under the plan”; plans are not required to cap out-of-pocket spending for services that are not essential health benefits. Similarly, the annual and lifetime limit requirements do not apply to “covered benefits that are not essential health benefits.”[SUP][4]

[/SUP]
As a result, if the definition of essential health benefits shrinks, the scope of the spending that is eligible for these protections shrinks as well. Indeed, if the essential health benefits standards were eliminated entirely, then these protections against catastrophic costs would become literally meaningless since no spending would be subject to the protections. To take a concrete example, suppose that a state modified essential health benefits requirements so that maternity care was no longer an essential health benefit. Plans could then require an enrollee to pay an unlimited amount out-of-pocket toward the cost of a delivery. Plans could also limit the total amount of delivery-related costs they would cover in any year or over a person’s lifetime.


Likely Consequences of the Essential Health Benefits Changes in the House Bill


The manager’s amendment filed Thursday night is reportedlyintended to eliminate the ACA’s federal essential health benefit requirements and instead allow each state to determine its own essential health benefits package. As noted previously, some have suggested that the drafting of the amendment makes its actual effect unclear. The discussion below proceeds under the assumption that the effect of the provision will in fact match the reported intent. Under this assumption, the degree to which this provision would affect the ACA’s protections against catastrophic costs depends on a few key factors.


The first factor is how states use their authority to determine essential health benefits. In states that set few or no standards, the out-of-pocket limit and annual and lifetime limit requirements would, for the reasons described above, become essentially meaningless. In states that maintained relatively stringent standards, there might be comparatively little effect on the integrity of the protections against catastrophic costs, although this would depend on the other considerations discussed below.


Experience from before the ACA implies that, in practice, many states would set standards much weaker than the existing federal standard. Prior to implementation of the ACA’s essential health benefit standards, an estimated 62 percent of individual market enrollees lacked coverage for maternity services, 34 percent lacked coverage for substance abuse services, 18 percent lacked coverage for mental health services, and 9 percent lacked prescription drug coverage. Consistent with the view that many states would set weak standards, the Congressional Budget Office has indicated that, in scoring this type of proposal, it would likely assume that regulatory approaches would “vary widely from state to state” and that “some states might not impose any regulations” on benefit designs.


The second factor is how employers that that offer large group and self-insured plans would be treated under this new regime. Current rules implicitly allow these employers to adopt the definition of essential health benefits that applies in any state they choose when determining their obligations with respect to the out-of-pocket limit requirement and the ban on annual and lifetime limits. If this approach were continued under this new regime, which seems plausible, then the catastrophic protections would be governed by the definition of essential health benefits in the states with the laxest standards, at least for large employers. In this case, the provision in the House bill would render the catastrophic protections essentially meaningless, at least as they apply to plans offered by large employers.


A final consideration is whether insurers might ultimately be permitted to sell plans across state lines, as the Administration has supported in the past. In that case, it is likely that employers of all sizes would be permitted to apply the essential health benefits standards that existed in the states with the laxest standards for the purposes of determining the scope of the ACA’s protections against catastrophic costs. As above, the consequence would be the complete or near complete elimination of the ACA’s protections against catastrophic health care costs. (While not the focus of this piece, allowing insurance across state lines would also magnify the consequences of devolving essential health benefits to the states for the individual health insurance market. As in the employer context, allowing sales across state lines would mean that the standards of the state with the laxest standards would end up applying nationwide.)


Conclusion


The ACA’s requirement that plans limit enrollees’ annual out-of-pocket spending and its ban on annual and lifetime limits have meaningfully improved the degree of financial protection offered by private insurance policies, including those offered by employers of all sizes. Because these protections only apply to services that are considered essential health benefits, the House’s proposal to devolve responsibility for defining essential health benefits to the states would have major implications for these protections.


For the reasons discussed above, there is strong reason to believe that, in practice, the definition of essential health benefits that applied to the catastrophic protections would be far weaker under the House proposal than under current law, seriously undermining these protections. These potential adverse effects on people with employer coverage, in addition to the potentially damaging effects of such changes on the individual health insurance market, are thus an important reason that policymakers should be wary of the House proposal with respect to essential health benefits.


[SUP][1][/SUP] The exception is grandfathered health plans, which are exempt from this requirement. The number of such plans is steadily dwindling over time.
[SUP][2][/SUP] I was Chief Economist at the Council of Economic Advisers at the time this estimate was prepared.
[SUP][3] The exception is grandfathered individual market policies, which are exempt from the annual limit requirements, but not the lifetime limit requirements.[/SUP]
[SUP][4] As noted above, unlike individual market and small group plans, self-insured and large employer plans are not required to cover the essential health benefits package, although they typically do cover most such services. For these large employers, the out-of-pocket limit and annual and lifetime limit requirements only apply with respect to the essential health benefits that are actually covered by the plan.[/SUP]
 

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What a jackass


Sahil Kapur
@sahilkapurRep. Peter King (R-NY) says he's "leaning toward" yes on AHCA mainly to get it to the Senate. "I would hope it gets changed over there."
 
superbeets

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[FONT=&quot]MR. SPICER: Well, I think both, in the sense that the MacArthur-Meadows amendment ensures that preexisting conditions continue to be covered. But then obviously as this bill hopefully passes the House this week, or whenever it does, and then goes through the Senate and the House, this is an issue that is important to him.[/FONT]
 
superbeets

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[FONT=&quot]MR. SPICER: So there’s two things -- and I think he mentioned in the same interview -- just to be clear, right now, under Obamacare, as it collapses on its own weight, people who have preexisting conditions are really the most vulnerable. Because if you have an insurance system that no longer is able to provide care to those who need it, then -- I think we’ve talked about this before -- you have a card without coverage.


[/FONT]
[FONT=&quot]So what the President is doing is ensuring, going forward as we attempt to repeal and replace it, that coverage of preexisting conditions is at the core of that. So that is something that he is ensured is in the current bill and we’ll continue to push for to make sure that coming out of the Senate and going to conference it’s there as well.[/FONT]
 
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[FONT=&quot]Trey.[/FONT]
[FONT=&quot]Q On healthcare, there seems to be a new optimism from the White House. How confident is the President that he will get a healthcare bill past the House this week?[/FONT]
[FONT=&quot]
MR. SPICER: I think the President has made it clear that he’s not instituting a timeline. I’ve said this before and I’ll continue to say that we feel confident the direction this is going. We see more and more members come on board. A lot of the changes that were made make the bill not only better but garner greater support. So we feel very good about it.[/FONT]
 

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superbeets said:
MR. SPICER: So there’s two things -- and I think he mentioned in the same interview -- just to be clear, right now, under Obamacare, as it collapses on its own weight, people who have preexisting conditions are really the most vulnerable. Because if you have an insurance system that no longer is able to provide care to those who need it, then -- I think we’ve talked about this before -- you have a card without coverage.



So what the President is doing is ensuring, going forward as we attempt to repeal and replace it, that coverage of preexisting conditions is at the core of that. So that is something that he is ensured is in the current bill and we’ll continue to push for to make sure that coming out of the Senate and going to conference it’s there as well.
Click to expand...
Lie...
 
superbeets

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[FONT=&quot]Q Thanks, Sean. Picking up on healthcare, it’s believed possibly that you might be down -- Republicans might be down to maybe just a handful of votes away. Here we are at 2:00 p.m. Monday afternoon. Is this the closest that you think you’ve gotten? I know you don’t want to talk about timelines, but is this as close to maybe getting to that magic 216 number that you’ve talked about?[/FONT]
[FONT=&quot]






MR. SPICER: Well, sure. We’re not going to -- once we get 216 we’ll stop counting. And I think the Speaker gets that. But as I mentioned to Trey, I mean, we’re getting closer and closer every day, so I would assume that today we’re closer than we were a week ago. But we’re not there yet, and that decision is going to be wholly within the Speaker, the Majority Leader and the Whip to let us know when they’re going to open that vote up.[/FONT]
 
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[FONT=&quot]Sarah.[/FONT]
[FONT=&quot]Q Thanks, Sean. So you’re saying that you’re not confident that the votes are lined up behind the healthcare bill. So this morning when Gary Cohn said that the bill was ready to be brought to the floor, did Gary Cohn misspeak? [/FONT]
[FONT=&quot]

MR. SPICER: No, I just -- I would never want to get in front of the Speaker. That’s up to them. We have a good whip count. I think we feel very good about where we are and where it’s headed. But ultimately, the Speaker and the House leadership determine when to call a vote. I think that we know that when the vote gets called we’ll feel confident that it’s going to be able to pass.[/FONT]
 
superbeets

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Mara.

Q Thank you, Sean. I have a healthcare and Israel question. On healthcare, when the President talks about a guarantee for preexisting conditions, current law says insurance companies have to sell to people with preexisting conditions, and they can’t charge them more than someone else in that area. Is that the guarantee that the President wants?

MR. SPICER: So the bill does not remove Obamacare’s guaranteed issue requirement. That’s it. And on the community ratings, the bill would allow states to waive Obamacare’s community rating requirement if certain conditions designated to preserve access to coverage for people with preexisting conditions are met. And there are reduced average premiums, increased enrollment, stabilize the market, stabilize premiums for those with preexisting -- the bottom line is to try to give the states flexibility to actually get that premium down.


Q Right, but people with preexisting conditions would continue to get access but not at the same price as other people.

MR. SPICER: Well, the idea is actually they would create a high-risk pool. The idea is actually to create a system where it gets the premium down for them as well.

Q Right. But high-risk pools could still charge them much more.

MR. SPICER: You can't -- you're right. When I say the whole goal of this is to give the states the flexibility to get lower premiums, that’s the goal all around, is to make sure that the system that we employ gets it down.
 

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[h=1]If GOP Passes Trumpcare, It’s Dead[/h][h=4]MICHAEL TOMASKY[/h]
[h=4]05.02.17 1:00 AM ET[/h]

https://twitter.com/intent/tweet?ur.../05/02/if-gop-passes-trumpcare-it-s-dead.html

http://www.reddit.com/submit?title=...care-it-s-dead.html?via=desktop&source=Reddit

Here’s the parallel universe Washington has become these days: The new Republican health care bill is even worse than the old ones, because they had to placate the hard-right members. Naturally, this worse bill seems to have a much better chance of passing.



House Republicans may hold a vote Wednesday. One presumes that after that late March fiasco, they now have the sense to schedule a vote if and only if they’re certain they have the votes for passage. They’ll be counting noses right up to Wednesday afternoon.


Passage of this bill into law would be a disaster for the country. Up to 20 million people could lose their health care coverage. People with serious illnesses could be screwed out of coverage again or charged far more than others under a provision that would allow states to bypass Obamacare requirements about covering those with preexisting conditions. The whopping cuts to Medicaid in the bill, wrote Jonathan Cohn Monday, would probably constitute the biggest single cut to a public benefit in the country’s history, bringing “widespread hardship to the millions of people who depend on it for everything from opioid treatment to cancer care.”



Fortunately, whatever the House does, the Senate seems, to most people watching this, like a heavier lift. Passage is certainly possible there—remember, Republicans wouldn’t need any Democratic votes to pass it under reconciliation, which also would mean the Democrats couldn’t filibuster it. Then the question would be whether three GOP senators would be willing to vote against Mitch McConnell—and of course their president. A second question would be whether McConnell really wants the GOP to be known as the party that threw 20 million people off their health insurance.


For the sake of those people, and all the others who’ll suffer under the Scrooge-Marley health care act, I can’t in decent conscience say that I hope the Republicans pass their bill. But right now, on my right shoulder, I’m feeling a little tap-tap-tap—it’s the little devil Tomasky, and he’s whispering in my ear: “C’mon, let ’em do it! They pass that bill and they’ll be handing the Democrats a huge pile of ammo for 2018! Write it!”


He’s right. If Trump and the Republicans actually do manage to repeal Obamacare, I think it would then be a near-certainty that they’d lose control of the House of Representatives. Why? Because a large number of the vulnerable House Republicans are in one of two circumstances, or sometimes both. One, they’re in states that took the Medicaid expansion, which means they’re representing many flesh-and-blood humans who will lose their coverage. Or two, they’re in districts that aren’t deep red, or are even a pale shade of blue, where approval for Obamacare is presumably pretty high.


For example, the Cook Political Report rates 13 seats held by Republican incumbents as being either toss-ups or “leaning” Republican, which means the incumbents are definitely vulnerable. Of the 13, eight are in states that took the Medicaid money. Of the remaining five, the Cook “partisan voting index,” which measures how Republican or Democratic a district is, either leans in the Democrats’ direction or is barely Republican in four. The only one of the 13 that on paper looks like it ought to be a fairly safe GOP seat is the Georgia seat that Democrat Jon Ossoff is seeking now (the election is June 20). But as we know, Ossoff appears to be the slight favorite.


Cook rates another 24 Republican-held seats as being possibly competitive. Of those 24 districts, 19 are in states that took the Medicaid dough. Most of those 19 would presumably vote against their own party on this one, but even so, they really don’t want to have to defend what their party will have done here, and as their Democratic opponents will inevitably be pointing out, “Congressman X may have voted against Ryancare, but he did vote to make Paul Ryan speaker, and Ryan made Ryancare happen.”


If they pass this bill, they are dead men (and women).


I think McConnell knows it. I imagine Ryan knows it, too, but he has that Freedom Caucus to assuage, so he has to press on. Does Trump know it? On Face the Nation Sunday, he was all over the place on the question of preexisting conditions and other matters. Of course, he insisted that people with such conditions were covered “beautifully.” When host John Dickerson informed him that the Republicans had passed an amendment to the opposite effect last week, Trump just waved it away. You’d think at this point that he’d actually care a little bit about substance, given that his success or failure now rides on the results he gets.


So here’s what we have: a Republican president who has lied repeatedly to the American people for nearly two years now about how he’d bring them health care coverage that was much cheaper and far better than Obamacare. And a Republican Congress that has lied repeatedly to the Americans for the last several years that they can pass a bill that’s vastly superior to Obamacare cuz, y’know, freedom. Trump’s lies were of ignorance; the GOP’s of ideological belief.


But even though they were different, they revealed the same truth: You can’t just magically make this better. It’s hard and complicated, and Obamacare can be improved, certainly, but only by people working in good faith to do so. The American people, finally, seem to have figured all this out.


I hope the House votes tomorrow, so they’re all on record. Then we’ll see where the fight goes from there.
 

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superbeets said:
Mara.

Q Thank you, Sean. I have a healthcare and Israel question. On healthcare, when the President talks about a guarantee for preexisting conditions, current law says insurance companies have to sell to people with preexisting conditions, and they can’t charge them more than someone else in that area. Is that the guarantee that the President wants?

MR. SPICER: So the bill does not remove Obamacare’s guaranteed issue requirement. That’s it. And on the community ratings, the bill would allow states to waive Obamacare’s community rating requirement if certain conditions designated to preserve access to coverage for people with preexisting conditions are met. And there are reduced average premiums, increased enrollment, stabilize the market, stabilize premiums for those with preexisting -- the bottom line is to try to give the states flexibility to actually get that premium down.


Q Right, but people with preexisting conditions would continue to get access but not at the same price as other people.

MR. SPICER: Well, the idea is actually they would create a high-risk pool. The idea is actually to create a system where it gets the premium down for them as well.

Q Right. But high-risk pools could still charge them much more.

MR. SPICER: You can't -- you're right. When I say the whole goal of this is to give the states the flexibility to get lower premiums, that’s the goal all around, is to make sure that the system that we employ gets it down.
Click to expand...

This is hilarious
 

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On Monday afternoon, Rep. Mo Brooks (R-AL) was asked by CNN’s Jake Tapper about House Republicans’ resurrected health insurance bill that the Trump administration is currently trying to muscle through Congress.

So far, at least 21 mostly moderate Republicans have said they planned to vote no on the revised bill, citing, among other things, the lack of protections for patients with pre-existing conditions. Despite assurances from Trump himself that Americans with pre-existing conditions would be protected from insurance providers cutting their coverage, the current House bill would allow states to give providers license to effectively deny insurance to anyone with a pre-existing condition by siphoning those individuals into so-called high risk pools, which are prohibitively expensive. The change was made at the behest of Brooks and his fellow members of the ultra-conservative House Freedom Caucus, which blocked the first version of Trumpcare because it wasn’t punitive enough.

But as Rep. Brooks sees it, being afflicted with a serious or life-threatening pre-existing condition is the price you pay if you don’t live a healthy lifestyle.

“My understanding is that it will allow insurance companies to require people who have higher health care costs to contribute more to the insurnace pool,” said Brooks. “That helps offset all these costs, thereby reducing the cost to those people who lead good lives, they’re healthy, they’ve done the things to keep their bodies healthy. And right now those are the people—who’ve done things the right way—that are seeing their costs skyrocketing.”

A study by the Centers for Medicare and Medicaid Services published in 2011 found that as many as half of Americans could be denied health insurance coverage due to a pre-existing condition, which is defined as any medical condition that existed prior to enrolling in health insurance. A cancer diagnoses would qualify as a pre-existing condition, but so too would asthma or even a pregnancy.

Rep. Brooks’ argument echos a similar one made by Speaker Paul Ryan (R-WI) several weeks ago when the House was debating the first version of Trumpcare. With a fancy chart by his side, Ryan bemoaned the unfairness of a system in which people who are generally healthy end up subsidizing the cost for people who need medical care. Why should healthy people shoulder some of the costs for sick people?

Of course, that is the very definition of insurance. It exists so that if you should suddenly fall ill, or sustain an unexpected injury, or are impregnated, your health costs don’t skyrocket.

Rep. Brooks seemingly acknowledged as much later on during his CNN interview. “In fairness, a lot of these people with pre-existing conditions, they have those conditions through no fault of their own,” he said. “And I think our society, under those circumstances, needs to help.” He’ll no doubt be pleased to know that Obamacare is the law of the land, and already provides protections for anyone with a pre-existing condition.
 
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