The Insider: Second Anniversary Check-in on the ACA

  ·  Health Policy Hub

With today’s blog we welcome back “The Insider,” Community Catalyst Policy Director Michael Miller, who will continue to provide an “inside out” perspective on major policy and political developments in the health policy arena. Though today’s blog is very Affordable Care Act-centric, future Insiders will delve into other non-ACA hot button health care issues.

More March Madness The folks who want to restrict women’s access to contraception simply don’t know when to quit. The best available polling shows that a majority of the public supports the ACA requirement that contraception be made available without cost-sharing with an exception for churches or other houses of worship. Although certain segments of the population (Republicans and white evangelical Protestants) are less supportive, independent voters are very supportive of the rule. So politically, the contraception jihad is clearly a loser. Interestingly, the Catholic Bishops notwithstanding, Catholics overall are more supportive of contraception coverage than the general population, and non-whites who identify as either Protestant or Catholic are even more supportive (so there is little chance the issue will drive Hispanic voters away from Democrats). But since the furor shows no signs of abating, here are two points too often overlooked in the debate.

First, employers were already prohibited from discriminating against women by refusing to cover contraception. In addition to numerous state laws, back in 2000, the Equal Employment Opportunity Commission ruled that refusal to cover contraception was a violation of the Civil Rights Act as amended by the Pregnancy Discrimination Act. The main thing the ACA actually does is remove the associated cost-sharing.

The second point is that health benefits don’t belong to employers, they belong to workers. Workers earn the benefits and give up wages in order to secure them. Therefore, the preferences of employers, religious or otherwise, are essentially irrelevant (or should be).

Pretzel Logic The ACA takes numerous steps to reduce the growth in health care spending. An effort to repeal one of those provisions, the Independent Payment Advisory Board (IPAB) created to develop ways to reduce Medicare spending, is likely to hit the House floor this week. Opponents of IPAB contend that the board’s recommendations will result in health care rationing or put government bureaucrats between patient and doctor. The truth is that IPAB is statutorily prohibited from reducing Medicare benefits.

As the House prepares to bring an IPAB repeal bill to the floor later this week, a number of Democratic supporters of the ACA appear poised to join in the IPAB repeal effort. Those Democrats who voted for the ACA and against the House Republican budget that proposed turning Medicare into a voucher program and are now contemplating a vote against IPAB are becoming nearly Romneyan in their ideological contortions. If you are against cutting benefits and increasing cost-sharing for Medicare beneficiaries, as proposed by the Republicans, and you are for reducing federal health spending, as would be achieved by the ACA, then voting against IPAB makes no sense. The alternative is likely to be the very kinds of Medicare cuts these Democrats have previously opposed.

To be sure, IPAB is not perfect. In particular it could be made better by making sure the board can consider payment and delivery reforms that will yield savings over multiple years. But there is plenty of time to fine-tune the IPAB rules since the board is not expected to file recommendations before 2018. The IPAB repeal vote is nothing more than yet another effort to distort what the ACA really does and undermine both the ACA and Medicare. Those who want to ensure Medicare cost containment is done correctly need to detach efforts to improve IPAB from efforts to weaken the ACA and Medicare program.

And speaking of undermining the Medicare program… Last year, the House Republican budget proposed to eliminate guaranteed Medicare benefits for future retirees and to turn the Medicaid program into a block grant to states that would shift billions in costs onto states and beneficiaries. Despite widespread popular opposition, House budget chairman Paul Ryan appears poised to double down on last year’s politically damaging proposals. Ryan insists that his budget is about reducing the federal debt, but in addition to punishing cuts affecting older people, people with disabilities and children and families, the plan is expected to include tax cuts for the wealthiest Americans. If nothing else, it offers Americans a picture of the difference between the two parties with respect to crucial health care programs.

I’m still waiting CMS just released two important sets of regulations—on Exchanges and Medicaid eligibility—that are currently being analyzed by Community Catalyst staff. And, of course, everyone is waiting for more information on federal Exchanges. But as we approach the second anniversary of the ACA, it is past time for the appearance of some other crucial regulations. Although they lack the marquee appeal of Exchange regulations, two topics that are particularly important to lower-income households have yet to be addressed: the Basic Health Plan option (BHP) and IRS rules governing financial assistance, charges, and debt collection for non-profit hospitals.

For those states moving forward with Exchange implementation, BHP regulations are needed so policymakers and consumer advocates can make an informed decision about whether to implement a BHP. The main reason for doing so is that a BHP could provide better benefits at a lower cost for lower-income people. Unless BHP guidance is released soon, there is substantial risk that those states most likely to consider a BHP will be too far down the road in their Exchange planning to give the option due consideration.

With respect to hospital financial assistance, the ACA contains provisions, nominally effective on passage, that would make it easier for uninsured and underinsured people to understand what financial assistance is available from their local hospitals and also to protect people from unreasonable collection actions. But almost two years later, no implementing regulations have been released, which means no improvements in access to care for uninsured and underinsured families. At least the IRS says financial assistance regulations are a priority to release this year (in contrast to CMS, which has been completely silent with respect to timing on the BHP). However, rumors of pushback on financial assistance regulations by hospitals persist, and there is as of yet no clear timeline for the regulations to be promulgated.

A new report from the Center for Disease Control shows that one in three people lives in a household struggling with medical debt makes it painfully clear that this is a problem that shouldn’t wait until 2014 to be addressed. The Obama administration obviously knows this is a problem since the CDC report is actually the second HHS report since passage of the ACA that underscores the problem of medical debt. They also have the power to do something about it by releasing the financial assistance regulations sooner rather than later. That would make a nice second anniversary present for uninsured and underinsured American families struggling to make their way back from the recession.

 -- Michael Miller, Policy Director