Over the weekend the National Association of Insurance Commissioners (NAIC) met in Denver, Colorado for their first meeting of 2017. Insurance commissioners and staff, industry representatives and consumer advocates gathered to discuss matters of insurance ranging from property and casualty issues like flood insurance to health insurance and the future of state implementation of the Affordable Care Act (ACA). On the health track, it was clear from the beginning that although attendees might be far from agreement on a range of issues, all would unite around one truth: uncertainty leads to instability, and instability breeds anxiety – especially in the health insurance market.

Chief among the causes of uncertainty – and most certainly the root of a lot of anxiety – is the future of the ACA’s cost-sharing reduction payments, which are the subject of a pending court case and ongoing debate between Congress and the Trump administration. While resolution to this issue remains mostly speculative, insurers worry about pricing products without knowing if they will receive these crucial payments, and regulators and consumer advocates worry this uncertainty will cause carriers to exit the ACA’s marketplaces leaving consumers with few coverage options in 2018.

Several other issues received attention from a range of stakeholders including the need for strong enrollment numbers in 2018 as well as how important enforcement of the individual mandate is to a stable individual market. The consumer representatives to the NAIC not only echoed many of these themes in their comments and presentations during committee meetings but also elevated how attempts to repeal and replace the ACA as well as pending administrative changes would negatively impact consumers.

In a newly released report, the health-focused consumer representatives highlight the ongoing need for consumer protections and stability amidst a time of federal uncertainty. At the meeting, they also stressed to state regulators the importance of finding ways to strengthen the individual market and the need to continue raising concerns to Congress and the administration as they introduce policies that could undermine coverage for consumers in their state. Commissioner Kreidler and the Association of Washington Healthcare Plans are leading the charge this week with a letter to HHS detailing their ideas for market stabilization as well as an important suggestion to explore ways to address affordability concerns for consumers. 

Time will tell if these messages make their way from Denver to D.C. However, when insurers, regulators and consumers all unite around one concern, reasonable minds should find that hard to ignore.

Movie sequels often fail to live up to the original, and Republicans' effort to repeal the ACA falls into this familiar pattern. As bad as the original was (and it was really bad), the sequel was even worse. Not content with taking health insurance away from 24 million people, increasing premiums and out-of-pocket costs for millions more, fundamentally undermining the Medicaid program, and shifting new costs onto states and providers, last week the Trump administration and House leaders continued to try to undermine health care coverage.

Fortunately, the revised proposal was quickly rejected and "pulled from the theatre." Republican lawmakers left town with nothing more to show for their flurry of activity than what appears to be a face-saving effort to get themselves out of the corner they painted themselves into when they attacked the idea of reinsurance as an "insurance industry bailout" by renaming it an "invisible high risk pool".

As much as this was a short-lived effort to bring the bill back to the floor, it contains two critical lessons:

First, if this was not already clear enough, President Trump's commitments on health care are meaningless. The huge gulf between his words and actions has been laid bare for everyone who doesn't have blinders on to see. Despite promising otherwise during the campaign, the original ACHA, which the Trump administration enthusiastically embraced, included a massive cut to Medicaid and even a cut to Medicare. It also undermined the insurance market reforms Trump promised to preserve by allowing states to waive Essential Health Benefits.

The EHB changes already in the AHCA would have undercut the ban on pre-existing condition exclusions by allowing the sale of insurance that excludes coverage for specific benefits or diseases while also exposing people to uncapped out-of-pocket charges. The proposed change in the rating rules would compound this by allowing insurers to charge people more based on their health status. These are devious proposals: while a guaranteed right to purchase would nominally remain, it would be virtually useless since insurers could charge sicker people such high premiums that coverage is priced out of reach.

Fortunately, the new deal collapsed for the same reason as the old one -- it was caught in a squeeze between the demands of the Freedom Caucus, which seeks an even more drastic rollback, and the outrage of an activated populace determined not to allow their health care to be stripped away.

Second, as in the typical horror flick, the monster can return from the dead multiple times. Despite the first failure, the House made a second effort, driven by the Trump administration, which again demanded they put a bill on the floor before April recess.

In a strange way, this abortive effort did us a favor. If anyone was feeling complacent after the collapse of the AHCA, the revived effort should have put people on notice. While the public outcry and GOP infighting have dealt ACA and Medicaid entitlement repeal a setback, the effort is far from dead. We should expect an effort to bring a bill back to the House floor in May, following the debate on spending for the remainder of 2017, which will occur in late April, and prepare accordingly. 

More Dragons on the Road Ahead

The AHCA, in whatever metastasized form, is not the only threat. Even if Republicans in Congress abandon a straight repeal effort, there are several other critical danger points. If, and when, Congress turns its attention to taxes, they are likely to need spending offsets to pay for (wait for it…) tax cuts for the rich. That could lead lawmakers back to looking at Medicaid (or the ACA) as a pay-for. Similarly, an effort to increase military spending might also create a hunt for spending offsets and put Medicaid and/or the ACA back on the chopping block. CHIP refinancing presents another "opportunity" for lawmakers predisposed to undermining the Medicaid financing structure.

Perhaps even more dangerous than these various legislative threats is the damage Congress and the Trump administration could inflict upon the ACA through both harmful actions and "malign neglect.” By creating a climate of uncertainty about the "rules of the road," including whether they will finance cost-sharing reductions and enforce the individual mandate, we can expect more insurance carriers to drop out of the Marketplace. This could leave more counties with only one option - and others with none at all (at least temporarily). Coupled with this uncertainty, and in the absence of action to improve the risk pool or a commitment to a robust enrollment push, we expect many insurers that stay in the Marketplace could seek another year of large rate increases. This could reverse the surge in popular support for the ACA and fuel the "ACA is broken" narrative.

To be very clear, ACA defenders are in a much stronger position after the defeat of the AHCA in the House, and there are plenty of things Congress or the states could do to lower premiums and cost-sharing and expand coverage, if they are so inclined. However, the bottom line is attacks on our health security are not going to subside any time soon. If people want to keep their health care, they are going to have to keep fighting to defend it. In other words, the only way to make sure this zombie stays in the ground is to keep shoveling dirt on the grave.

With thanks to Quynh Chi Nguyen, policy analyst, for her assistance.


“Now this is not the end. It is not even the beginning of the end. But it is, perhaps, the end of the beginning.”

– Winston Churchill, 1942

On the heels of the 7th anniversary of the signing of the Affordable Care Act (ACA), House Republican leadership abruptly withdrew the American Health Care Act – their plan for repealing and replacing the ACA – from a long-promised floor vote. Many of us breathed a (brief) sigh of relief, particularly for the 24 million Americans who could have lost their health care coverage if this bill had been enacted.

But even as we celebrate the integral role consumers – including many older adults and people with disabilities – played in defeating the bill, the work to improve health care is as urgent and pressing as ever. Now that we’ve reached what we hope is the “end of the beginning,” here are three things we’re doing here at the Center to create a more person-centered health care system:

Identify and disseminate innovative models of care.

There has been tremendous progress in the development and rollout of innovative models of care that improve health and outcomes, often while saving money at the same time. For example, Massachusetts’ Community Support Program for People Experiencing Chronic Homelessness (CSPECH) provides supportive services to help people obtain and stay in housing. The benefits in quality of life and improved health have resulted in annual per-person net savings of up to $7,013. This year, the Center will highlight innovations that are person-centered, responsive to the needs of the community and built with consumer input in a series of publications we’re calling, “What Works.”

Build a network of consumers who can drive health care innovation.

Consumers have a unique and critical role to play in ensuring that health innovation efforts result in care that is oriented around the needs of the people served. As such, the Center recently awarded a series of grants, with more on the way, to help state consumer advocacy organizations build out a base of consumers – particularly older adults, people with disabilities and those from communities of color – who can drive person-centered care innovation in their states. Over the next year and supported by one-on-one technical assistance provided by the Center, our grantees plan to reach out to 22,000 consumers, sign up roughly 2,000 consumers to engage with our partners and develop 90-100 new consumer leaders who can advance health care innovation.

Stand up for person-centered care.

Despite the AHCA’s late March collapse in the House, I expect that there will continue to be threats to comprehensive, person-centered care. For one thing, there may be more attempts at “repeal and replace”. But even short of repeal, threats might come in the form of policies that limit eligibility for and/or complicate enrollment into coverage, increase financial barriers for accessing care, take away support for innovative care models, or reduce services (for example, non-emergency medical transportation) that we know are critical for health and which are cost-effective, too. As new proposals come forward, we will assess them through the lens of whether they will improve health, particularly for people with complex health and social needs, and we will continue to sound the alarm about programs that co-opt the language of person-centeredness to instead impose policies that hurt the most vulnerable.

While March 24, 2017 perhaps marked the end of one chapter in the history of health care policy in the United States, it is certainly not the end of the journey to improve health care. We have much work ahead and I look forward to sharing this journey and its inspirations, challenges and, hopefully, celebrations as we move forward.

What’s the one thing you’d change about the health system tomorrow to make it more patient-centered? Tweet us @ccehi and share your thoughts!

Last week, President Trump launched his Commission on Combating Drug Addiction and the Opioid Crisis. While we appreciate the president’s attention to the issue, his first formal action to address substance use leaves us feeling underwhelmed and concerned about the administration’s approach to addiction.

The Opioid Commission is tasked with gathering and reporting on best practices for addressing drug misuse, and making recommendations for action. Sound familiar? The Surgeon General’s report published last November did exactly that. We can’t allow the administration to hide behind this empty gesture – they need to act now to address the problem, based on the non-partisan, comprehensive information and policy recommendations in the Surgeon General’s report. What we need is an immediate investment in community prevention programs, evidence-based treatment and recovery support services.

Also troubling is the apparent over-representation of law enforcement on the Commission. New Jersey Governor Chris Christie, a former U.S. Attorney, will chair the committee. The member list has not been formally announced, but is expected to include Attorney General Jeff Sessions, Defense Secretary James Mattis, and Florida Attorney General Pam Bondi, among others. Where is the representation of advocates for people with substance use disorders, leading providers of comprehensive services, the experts at the Substance Abuse and Mental Health Services Administration and the Surgeon General himself?  

In recent years we have made strides in shifting our attitude about substance use, from blaming and incarcerating people for their illness to offering treatment and support instead, but the composition of the Commission raises concerns about the approach the administration plans to take to address drug use. 

We’re beginning to see other state and national policies that reflect old attitudes about drug use. Wisconsin’s recent Medicaid waiver proposal includes drug testing certain Medicaid recipients. A Congressional resolution signed by the president on Friday now allows states to drug test any recipients of unemployment benefits.

When we have 91 Americans dying from opioid overdoses every day and 2.3 million people in the criminal justice system, we can’t afford to go back to the failed war on drugs. Not only are these policies ineffective, but they disproportionately affect people of color who are arrested at higher rates and sentenced more severely for the same offenses than their white peers.

Advocates need to remain vigilant and push back against rhetoric that perpetuates blame and policies that use punitive approaches to address substance use. In a “listening session” this week, the president talked about an approach emphasizing “law enforcement and prevention.” We need to urge the administration to act using the approaches proven to work: prevention, treatment and recovery supports.

I recently had the privilege of joining partner advocates at the Rhode Island Organizing Project (RIOP) at a “house meeting” in the Providence community. RIOP staff have long used house meetings as a powerful organizing tool, gathering consumers in comfortable settings in or near their homes to engage in meaningful conversations on important issues that affect their health and well-being. The gatherings have a particular focus on vulnerable and historically disempowered populations such as low-income older adults and people with disabilities, including those in minority communities.

This meeting was at a low-income senior housing residential building. There were 12 attendees and eight were Spanish speakers with limited proficiency in English. I was so happy to be there and have the opportunity to hear from the Latino community while serving as a translator for the RIOP organizer. The major issues attendees talked about were their difficulty in getting access to home-based care and needed dental, vision and hearing coverage. Several older adults also spoke about their isolation, which was very compelling.

This was the first time that RIOP organizers were reaching out at the residential level to the Latino population in Providence. They were able to provide vital information about help with the new 50-cent fare on the city bus system for people with disabilities and adults over age 65. Previously, those two groups rode Rhode Island Public Transit Authority (RIPTA) buses free. RIOP and other advocates fought hard against this new fare over the past years, but it went into effect in February of this year. Now that it’s here, the one option to soften the blow is a RIPTA card that provides 10 free trips monthly. This is not much, but it is vital assistance to low-income people struggling to balance all their needs each month on very limited funds. RIPTA had posted the application for this program online in several languages, including Spanish, but finding it requires access to and familiarity with computer use. So, for many of these Spanish speaking folks, this was the first time they were learning about this benefit’s existence. After the meeting, they went directly to City Hall to obtain their 10-ride bus passes. 

They also learned about the new INTEGRITY Plan, the state’s recently launched dual eligible demonstration project at Neighborhood Health Plan of Rhode Island for older adults that coordinates all Medicare and Medicaid benefits and services. Some of those eligible had received letters in Spanish about this new plan but still needed more information and clarification. They were confused as to why their existing insurance plan was asking them to consider this new plan, and worried about making any changes that might interrupt their current care. The RIOP advocates were able to provide them with the contact number of the ombudsman program for the Integrity plan, which offers information in Spanish. 

These were two practical and empowering things these consumers learned about at the meeting.

What this experience reinforced for me is how much people long to be heard and understood. I learned that there is a pressing need for health care information for the Latino population. It is not enough to simply know about their issues and fight for what we think will benefit them, but that we need to be able to meet and engage personally with people across a diverse range of communities. That is what the advocates in Rhode Island are doing by revealing their presence to this community. They are building meaningful new relationships; they are building bridges. RIOP advocates understand that all people have the right to be informed of decisions that affect them, to be involved in the process and to participate actively in their own health care. By attending these meetings, sharing their stories and partnering with local advocates, consumers from diverse language communities can in turn play a major role in working for just, consumer-centered health care policies.