Could their be a bipartisan Obamacare fix?

bipartisan Obamacare fixRepublican efforts to repeal and replace the Affordable Care Act appear to be dead – at least for now. But two U.S. senators may soon unveil a bipartisan proposal to make modest healthcare fixes.

Sen. Lamar Alexander (R-Tenn.), chairman of the Senate Health, Education, Labor, and Pensions Committee, and Sen. Patty Murray (D-Wash.), the committee’s ranking member, are back at work negotiating a bipartisan plan, according to reports in The Hill, Politico and elsewhere.

Alexander told Politico on Sept. 29 that there might be a piece of legislation ready for Senate leaders by the end of this week.

The deal reportedly would safeguard Obamacare exchange subsidies, which President Donald Trump’s administration has threatened to pull, while giving states more leeway when it comes to the ACA’s requirements. States could potentially have more freedom to offer cheaper, less generous plans on the insurance exchanges.

Whether the proposal will gain traction is anyone’s guess, though Trump has started to show a willingness to sometimes cut deals with Democrats.

Repealing and replacing the Affordable Care Act was a top priority for Trump and the Republican Congress. But as Trump famously (or infamously) said last February as the debate heated up, “Nobody knew health care could be so complicated.” With an end-of-September deadline looming, Republicans made a last push in September with the Graham-Cassidy bill, but the bill was pulled Sept. 26.

Efforts to repeal and replace received another blow on Sept. 29 when Tom Price resigned from his post as U.S. health and human services secretary. Price – a longtime ACA critic when he was a U.S. representative from Georgia – had been a point person for rolling back executive branch efforts to promote Obamacare.

The post Could their be a bipartisan Obamacare fix? appeared first on MassDevice.

Republicans are stuck on healthcare but they have no choice but to persevere

Republican health analysts said party officials had little choice but to keep trying to reach consensus — or at least enough consensus to pass a bill out of the House.

Will Anthem exit the ACA exchanges?

Anthem could be the next insurer on the block to depart from the Affordable Care Act exchanges.

A recent report from Jefferies analysts, who claimed they met with Anthem, found the insurer might be planning to drop from the exchanges next year. Analysts David Windley and David Styblo said Anthem “is leaning toward exiting a high percentage of the 144 rating regions in which it currently participates.”

Bloomberg initially reported news of the Jefferies analysis.

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According to the report, Anthem told Jefferies analysts that “regulatory advocacy needs to progress significantly in the next ‘month or so.’” In Anthem’s opinion, “[i]mprovements such as eligibility verification, more rigid special enrollment periods, shortening of premium grace periods are steps in the right direction, but not enough,” the analysts wrote, according to CNBC.

Anthem, which sells plans under the Blue Cross Blue Shield Brand, has a little more than 800,000 individual exchange plan customers in 14 states.

However, the insurer hasn’t been doing so hot fiscally, according to Bloomberg Intelligence. It lost approximately $374 million on individual plans in 2016. Its 2017 financial goals are moderate, and an estimated 8.6 percent of its revenue will come from individual plans.

If Anthem does decide to pull back, it could create the most significant coverage gaps in states like Colorado, Georgia, Kentucky, Missouri and Ohio, according to a New York Times report. An analysis from the Robert Wood Johnson Foundation determined an Anthem departure would leave people in almost 300 counties without an insurance carrier.

The insurer’s potential exit isn’t altogether surprising. Anthem CEO Joseph Swedish hinted at it during a call regarding fourth quarter results with Wall Street analysts. “We will make the right decisions to protect the business,” he said, according to Bloomberg. “If we can’t see stability going into 2018, with respect to either pricing, product or the overall rules of engagement, then we will begin making some very conscious decisions with respect to extracting ourselves.”

In an emailed statement to Bloomberg, Anthem said it’s working with the Trump administration “to emphasize the importance of regulatory and statutory changes in order to ensure sustainability and affordability of the individual market for consumers” and that it will “actively pursue policy changes that will help with market stabilization and achieve the common goal of making quality healthcare more affordable and accessible for all.”

Anthem’s likely departure points to a larger trend among insurers offering plans on the ACA exchanges. Earlier this year, Humana said it will completely stop offering individual plans on the exchanges in 2018. UnitedHealth Group and Aetna have also scaled back on their ACA offerings.

Photo: Hero Images, Getty Images

How did it come to this? Ryan and Trump pull healthcare bill after coming up short on votes.

U.S. Speaker of the House Paul Ryan answers questions at a press conference at the U.S. Capitol after President Trump’s healthcare bill was pulled from the floor of the House of Representatives. (Photo by Win McNamee/Getty Images)

Despite days of intense negotiations and last-minute concessions to win over wavering GOP conservatives and moderates, House Republican leaders Friday failed to secure enough support to pass their plan to repeal and replace the Affordable Care Act.

House Speaker Paul Ryan pulled the bill from consideration after he rushed to the White House to tell President Donald Trump that there weren’t the 216 votes necessary for passage.

“We came really close today, but we came up short,” he told reporters at a hastily called news conference.

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When pressed about what happens to the federal health law, he added, “We’re going to be living with Obamacare for the foreseeable future.”

Ryan originally had hoped to hold a floor vote on the measure Thursday — timed to coincide with the seventh anniversary of the ACA — but decided to delay that effort because GOP leaders didn’t have enough “yes” votes. The House had been in session Friday while members debated parts of the bill.

The legislation was damaged by a variety of issues raised by competing factions of the party. Many members were spooked by reports by the Congressional Budget Office showing that the bill would lead eventually to 24 million people losing insurance, while some moderate Republicans worried that ending the ACA’s Medicaid expansion would hurt low-income Americans.

At the same time, conservatives, especially the hard-right House Freedom Caucus that often has needled party leaders, complained that the bill kept too much of the ACA structure in place. They wanted a straight repeal of Obamacare, but party leaders said that couldn’t pass the Senate, where Republicans don’t have enough votes to stop a filibuster. So they chose to use a complicated legislative strategy called budget reconciliation that would allow them to repeal only parts of the ACA that affect federal spending.

The decision came after a chaotic week of negotiations, as party leaders sought to woo more conservatives. Trump personally lobbied 120 members through personal meetings or phone calls, according to a count provided Friday by his spokesman, Sean Spicer. “The president and the team here have left everything on the field,” Spicer said.

On Thursday evening, Trump dispatched Office of Management and Development Director Mick Mulvaney to tell his former House GOP colleagues that the president wanted a vote on Friday. It was time to move on to other priorities, including tax reform, he told House Republicans.

“He said the president needs this, the president has said he wants a vote tomorrow, up or down. If for any reason it goes down, we’re just going to move forward with additional parts of his agenda. This is our moment in time,” Rep. Chris Collins (R-New York), a loyal Trump ally, told reporters late Thursday. “If it doesn’t pass, we’re moving beyond health care. … We are done negotiating.”

Trump’s edict clearly irked some lawmakers, including the Freedom Caucus chairman, Rep. Mark Meadows (R-North Carolina), whose group of more than two dozen members represented the strongest bloc against the measure.

“Anytime you don’t have 216 votes, negotiations are not totally over,” he told reporters who had surrounded him in a Capitol basement hallway as he headed into the party’s caucus meeting.

Shortly before Ryan’s press conference, Trump called Washington Post reporter Robert Costa to say they were pulling the bill back from consideration. Costa said the president seemed at ease with the decision and did not blame Ryan for the defeat.

Trump, Ryan and other GOP lawmakers tweaked their initial package in a variety of ways to win over both conservatives and moderates. But every time one change was made to win votes in one camp, it repelled support in another.

The White House on Thursday accepted conservatives’ demands that the legislation strip federal guarantees of essential health benefits in insurance policies. But that was another problem for moderates, and Democrats suggested the provision would not survive in the Senate.

Republican moderates in the House — as well as the Senate — objected to the bill’s provisions that would shift Medicaid from an open-ended entitlement to a set amount of funding for states that would also give governors and state lawmakers more flexibility over the program. Moderates also were concerned that the package’s tax credits would not be generous enough to help older Americans — who could be charged five times more for coverage than their younger counterparts — afford coverage.

The House package also lost the support of key GOP allies, including the Club for Growth and Heritage Action. Physician, patient and hospital groups also opposed it.

It’s not clear what will happen next to the Republican effort to overturn or modify Obamacare. But White House officials told members Thursday that if they couldn’t pass the legislation, the president wanted to turn to other priorities, including tax reform. “The president understands this is it,” Spicer said. “We had this opportunity to — to change the trajectory of health care, to help improve — put a health care system in place and to end the nightmare that Republicans have campaigned on called Obamacare.”

As House health bill vote nears, what would be consequences of dumping essential benefits?

A last-minute attempt by conservative Republicans to dump standards for health benefits in plans sold to individuals would probably lower the average consumer’s upfront insurance costs, such as premiums and deductibles, said experts on both sides of the debate to repeal and replace the Affordable Care Act.

But, they add, it will likely also induce insurers to offer much skimpier plans, potentially excluding the gravely ill, and putting consumers at greater financial risk if they need care.

For example, a woman who had elected not to have maternity coverage could face financial ruin from an unintended pregnancy. A healthy young man who didn’t buy drug coverage could be bankrupted if diagnosed with cancer requiring expensive prescription medicine. Someone needing emergency treatment at a non-network hospital might not be covered.

What might be desirable for business would leave patients vulnerable.

“What you don’t want if you’re an insurer is only sick people buying whatever product you have,” said Christopher Koller, president of the Milbank Memorial Fund and a former Rhode Island insurance commissioner. “So the way to get healthy people is to offer cheaper products designed for the healthy people.”

The proposed change could give carriers wide room to do that by eliminating or shrinking “essential health benefits” including hospitalization, prescription drugs, mental health treatment and lab services from plan requirements — especially if state regulators don’t step in to fill the void, analysts said.

The Affordable Care Act requires companies selling coverage to individuals and families through online marketplaces to offer 10 essential benefits, which also include maternity, wellness and preventive services — plus emergency room treatment at all hospitals. Small-group plans offered by many small employers also must carry such benefits.

Conservative House Republicans want to exclude the rule from any replacement, arguing it drives up cost and stifles consumer choice.

On Thursday, President Donald Trump agreed after meeting with members of the conservative Freedom Caucus to leave it out of the measure under consideration, said White House Press Secretary Sean Spicer. “Part of the reason that premiums have spiked out of control is because under Obamacare, there were these mandated services that had to be included,” Spicer told reporters.

Pushed by Trump, House Republican leaders agreed late Thursday to a Friday vote on the bill but were still trying to line up support. “Tomorrow we will show the American people that we will repeal and replace this broken law because it’s collapsing and it’s failing families,” said House Speaker Paul Ryan (R-Wisconsin). “And tomorrow we’re proceeding.” When asked if he had the votes, Ryan didn’t answer and walked briskly away from the press corps.

But axing essential benefits could bring back the pre-ACA days when insurers avoided expensive patients by excluding services they needed, said Gary Claxton, a vice president and insurance expert at the Kaiser Family Foundation. (Kaiser Health News is an editorially independent program of the foundation.)

“They’re not going to offer benefits that attract people with chronic illness if they can help it,” said Claxton, whose collection of old insurance policies shows what the market looked like before.

One Aetna plan didn’t cover most mental health or addiction services — important to moderate Republicans as well as Democrats concerned about fighting the opioid crisis. Another Aetna plan didn’t cover any mental health treatment. A HealthNet plan didn’t cover outpatient rehabilitative services.

Before the ACA most individual plans didn’t include maternity coverage, either.

The House replacement bill could make individual coverage for the chronically ill even more scarce than a few years ago because it retains an ACA rule that forces plans to accept members with preexisting illness, analysts said.

Before President Barack Obama’s health overhaul, insurers could reject sick applicants or charge them higher premiums.

Lacking that ability under a Republican law but newly able to shrink benefits, insurers might be more tempted than ever to avoid covering expensive conditions. That way the sickest consumers wouldn’t even bother to apply.

“You could see even worse holes in the insurance package” than before the ACA, said Sabrina Corlette, a research professor at the Center on Health Insurance Reforms at Georgetown University. “If we’re going into a world where a carrier is going to have to accept all comers and they can’t charge them based on their health status, the benefit design becomes a much bigger deal” in how insurers keep the sick out of their plans, she said.

Michael Cannon, an analyst at the libertarian Cato Institute and a longtime Obamacare opponent, also believes dumping essential benefits while forcing insurers to accept all applicants at one “community” price would weaken coverage for chronically ill people.

“Getting rid of the essential health benefits in a community-rated market would cause coverage for the sick to get even worse than it is under current law,” he said. Republicans “are shooting themselves in the foot if they offer this proposal.”

Cannon favors full repeal of the ACA, allowing insurers to charge higher premiums for more expensive patients and helping consumers pay for plans with tax-favored health savings accounts.

In an absence of federal requirements for benefits, existing state standards would become more important. Some states might move to upgrade required benefits in line with the ACA rules but others probably won’t, according to analysts.

“You’re going to have a lot of insurers in states trying to understand what existing laws they have in place,” Koller said. “It’s going to be really critical to see how quickly the states react. There are going to be some states that will not.”

Mary Agnes Carey and Phil Galewitz contributed to this story.

Photo: byakkaya, Getty Images

White House delivers ultimatum on healthcare bill, setting scene for dramatic House vote Friday

There’s so much drama on Capitol Hill today and this evening. After years of failed attempts, the Republicans are finally positioned to repeal and replace the Affordable Care Act. But the vote, which was expected to take place Thursday, was delayed as it became clear that there weren’t enough votes from the conservative members of the “Freedom Caucus” and moderate members of the House Republicans to push the bill through.

Who would have thought there was so much diversity in the Republican party?

Republican leadership met with White House officials and party members Thursday evening to sway undecided or no voters to a yes. The White House also delivered an ultimatum to Republicans considering a no vote: Negotiations are over. Vote yes or move on with Obamacare.

If the bill is defeated, what would that say about the Trump’s negotiating skills? After all, Press Secretary Sean Spicer quipped at a media briefing yesterday, “There is no Plan B”.

The turn of events provoked plenty of discussion about what this vote means for the Republican party’s identity, whether Trump is setting House Speaker Paul Ryan as a scapegoat and evaluating the job Trump has done selling the healthcare bill to the American voters.

Amidst the drama, there was some room for a little comedy

And some apologizing…

A Congressional Budget Office Report published Thursday afternoon contended that under the revised bill 24 million would still lose their health insurance by 2026, despite reducing savings in federal spending.

The Republicans occupy a position they have strived to be in for years and yet as the bill makes it final approach to the floor of the House, Congressmen are feeling the full weight of this vote and the growing realization that some of the constituents will like it but many of them won’t. Just as passing ACA led many Americans to lose insurance when their previous plans became voided by the Act’s requirements, there will be winners and losers with this bill as well.

At the very least, there will be a lot of questions to address in the next 24 hours, whatever the outcome.

Photo: Justin Sullivan, Getty Images

D-Day for the ACA?

If you are a sports fan, March is your month. The past week has been filled with near non-stop coverage of the NCAA tourney, and there are still a few more weeks to go.

However, if you are apathetic toward sports and filled out a bracket at the last minute only out of office-pool guilt (like I did), then March is your month for a whole other reason. Not only have SCOTUS confirmation hearings happened this week, but the very fate of the Affordable Care Act (ACA) is up for a vote in the House of Representatives today as well.

Regardless of where you sit on the political spectrum, and whether you have found this week exciting of terrifying, you have to admit that it has been captivating. But even with all of this Kardashian-esque drama, frankly I am ready for it to be over!

That is not a political statement, nor is this a political post.

Repeal and replace the ACA versus amending and improving? I will leave it to you to turn to your favorite cable news channel for the latest on that debate. Rather, as in-house for a hospital network, I am ready for the whole debate to be done so a little certainty can return to our business operations and give our patients some peace of mind.

I have been fielding “what if the ACA goes away” hypotheticals since Trump won the Republican nomination last summer. I have been contemplating what a post-ACA life would look like for our hospital network with renewed vigor since Trump won in November. I have worked Biglaw-like hours since the House introduced its repeal bill a couple of weeks ago. And frankly, I am tired.

I am tired of monitoring CNN and Fox News simultaneously for the latest breaking news or theories on the repeal measure.

I am tired of explaining to my non-legal colleagues that reconciliation in Washington, D.C. has nothing to do with being a Catholic.

And I am tired of reviewing hastily drafted bills and amendments and evaluating their potential impact on our organization and our patients.

I understand this sort of work comes with the territory of being in-house, and I am happy to do it. Sadistically, as a self-professed political nerd, I even enjoy it. However, any real appreciation the present ACA debate is having on thousands of hospitals and millions of patients across the nation seems to be absent from the current political debate in Washington.

If you are a patient currently covered by expanded Medicaid coverage or if you are a family with insurance paid for by a subsidy, the fact that the AHCA would not take effect until 2020 is likely of little solace to you. Similarly, if you are an insurance company or a hospital attempting to forecast your financials for the coming years, the current political instability may cause you to rethink your future staffing model.

While I have my own opinions as to what health reform in America should look like I understand, just like March’s sports fans, there are winners and losers. And I am happy to respect whatever sort of outcome our elected officials in D.C. do, or do not, implement. However, our health care system is already shaky enough as is, without the political interjections every few years.

Whatever happens in D.C. today, I and my fellow in-house counsel in the healthcare sector will prepare for it. But please recognize this is not a fire drill we can engage in every four to eight years.

Yes, it may be painful, but reach across the aisle and find a solution both parties can live with for many years to come.

Not only will I thank you on behalf of my in-house colleagues, but on behalf of the millions of patients across the country who can now focus on getting  better, not on whether their health insurance coverage is still valid.


Stephen R. Williams is in-house counsel with a multi-facility hospital network in the Midwest. His column focuses on a little talked about area of the in-house life, management. You can reach Stephen at stephenwilliamsjd@gmail.com.

What do small business owners think of the AHA, AHCA?

Everyone has an opinion on the American Health Care Act, the new GOP plan to replace the ACA.

A new poll from the Small Business Majority surveyed 500 small business owners from across the country on their opinions on the AHCA. The survey was conducted online between March 17 and March 20 and had a +/- 4.5 percent margin of error.

Survey respondents came from a variety of backgrounds. Forty-eight percent were as male, while 52 percent were female. The majority of respondents (33 percent) were between the ages of 30 and 44, with the next largest proportions coming from the 45 to 54 age range (21 percent) and the 55 to 64 age range (20 percent).

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In a tele-press conference on March 23, Small Business Majority founder and CEO John Arensmeyer discussed what prompted the poll. “We’ve been intimately involved for years talking with small business owners about the ACA,” he said. “With the proposed changes in Congress, we knew this was a huge issue for small business owners.”

Near the beginning of the survey, respondents were asked about their existing knowledge of the ACA. Forty-eight percent of respondents admitted to only knowing “some” about the ACA. Another 24 percent said they knew “a great deal” about it, and 20 percent said they knew “not too much.” Five percent indicated they knew “nothing at all” about the ACA.

Next, the survey questioned respondents as to whether they support or oppose the ACA. Initially, 25 percent of respondents said they strongly support the ACA, while 29 percent said they strongly oppose it.

However, after answering a series of questions about their opinions on certain provisions of the ACA, respondents’ opinions changed slightly. Thirty-one percent said they strongly support the ACA and 24 percent said they strongly oppose it.

The poll then added the AHCA to the mix, initially asking respondents how much they knew about it. Thirty-five percent admitted to knowing “some” about it. Another 16 percent said they knew “a great deal” about the AHCA, and 28 percent said they knew “not too much.” Eighteen percent of respondents admitted to knowing “nothing at all” about the proposed plan.

Once again, the survey asked respondents whether they support or oppose the AHCA. Initially, 14 percent said they strongly support it and 27 percent said they strongly oppose it. After answering questions about specific provisions of the AHCA, respondents’ opinions changed. Fourteen percent of respondents said they strongly support the AHCA, and 33 percent said they strongly oppose it.

Finally, the survey asked respondents whether they would choose the ACA or the AHCA. Thirty-nine percent of respondents were strongly in favor of choosing the ACA, and 10 percent said they would choose the ACA but weren’t as strongly for it. Meanwhile, 16 percent said they were strongly in favor of the AHCA, and 10 percent said they would choose the AHCA but weren’t as strongly for it. Interestingly, 14 percent said they’d choose neither the ACA or the AHCA.

In a press release, the Small Business Majority noted that survey respondents were “politically diverse.” They seem to be, as 28 percent of respondents identified as Democrats, 27 percent identified as Republicans and 38 percent identified as Independents. The remaining 5 percent either indicated “other,” “don’t know” or refused to answer.

However, it’s important to note that a contributor to Forbes and The New York Times has said the Small Business Majority is left-leaning.

Photo: prinaka, Getty Images 

Editor’s note: This article has been updated to reflect that the same contributor wrote in Forbes and The New York Times that the Small Business Majority is left-leaning. A spokesperson for the Small Business Majority also told MedCity that the polling firm used for the survey, Chesapeake Bay Consulting, is right-leaning.

House GOP tosses individual mandate from ACA replacement but adds penalty for insurance lapses

The Affordable Care Act’s tax penalty for people who opt out of health insurance is one of the most loathed parts of the law, so it is no surprise that Republicans are keen to abolish it. But the penalty, called the individual mandate, plays a vital function: nudging healthy people into the insurance markets where their premiums help pay for the cost of care for the sick. That has required Republican lawmakers to come up with an alternative.

The GOP approach is called a “continuous coverage” penalty. It increases premiums for people who buy insurance if they have gone 63 consecutive days without a policy during the past 12 months. Their premiums would rise by 30 percent and that surcharge would last for a year. While the ACA assesses a fine for each year people don’t buy insurance, the GOP plan would punish those who decide to purchase it after not being in the market.

Much is at stake. If this approach fails to prod enough healthy people into buying insurance, rates for everyone else in the insurance pool will rise, destabilizing promises by President Donald Trump and GOP leaders to make their Obamacare replacement more affordable. The nonpartisan Congressional Budget Office projects that millions fewer people will buy insurance if the individual mandate is repealed and replaced with a continuous coverage surcharge.

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Why do people allow their insurance to lapse?

Some simply can’t afford the premiums, like Sheila Swartz. She and her husband, Don, who has a heart condition, dropped their policy in December after learning monthly premiums were going to increase by about $140 to $530. “You can’t get blood out of a turnip,” said Swartz, who lives outside Nashville, Tenn., and works as a house cleaner. “If you can’t afford that premium, you can’t afford that premium.”

This KHN story also ran on NPR. It can be republished for free (details).
Others stop paying premiums when they lose a job or are hit with unexpected costs in other areas, such as major home or car repairs. “If you have to pay rent or health insurance, you are probably not going to choose health insurance,” said Bruce Jugan, a health insurance broker in Montebello, Calif.

Some people try to game the system, taking the calculated risk of going without insurance until they get sick or know they need expensive medical care, such as for maternity or an elective surgery.

Both the Affordable Care Act and the GOP proposal include a deterrent by limiting people from enrolling anytime they want. People must wait for annual enrollment periods, usually in the final weeks of the year, meaning that some people might have to wait months before getting coverage. (People still can get insurance during special enrollment periods if they lose a job, get divorced or have another specified major life change.)

How tough is the GOP penalty compared with the individual mandate?

Under the ACA, the average individual mandate penalty in 2015 was $442, according to the Internal Revenue Service.  The GOP penalty would vary based on cost of premiums but generally would be more expensive than paying the mandate’s penalty. A 40-year-old with annual premiums of $4,328 would pay an extra $1,298 because of the GOP surcharge.

“It’s got teeth,” said Cheryl Damberg, a Rand Corp. economist. “In some ways, it’s a more punishing penalty, and it’s going to hit people who are least capable of financially affording it.”

Seth Chandler, a law professor at the University of Houston Law Center who has been critical of the Affordable Care Act’s insurance markets, said he is skeptical the GOP surcharge is high enough to make people enroll. “I am concerned that the Republicans are succumbing to the same softness of heart as the Democrats succumbed too when they set the individual mandate [fine],” he said. “If you start to see insurance companies object or drop out of the markets, that’s a sign this thing is miscalculated.”

Two conservative economists at the American Enterprise Institute, Joseph Antos and James Capretta, argue the penalty is “far too small” to be effective. “Healthy consumers are likely to take their chances,” they wrote. “With the repeal of the individual mandate, and the retention of the ACA’s insurance rules, the overall effect would be significant market turbulence, starting immediately in 2017.”

The CBO predicts that there would be a brief increase in the number of people holding insurance in 2018, as roughly 1 million people buy coverage to avoid the surcharge. In most years afterward, however, about 2 million fewer people would buy policies, either because of the surcharge or because of the requirement they provide documentation proving they had been insured. The CBO said healthy people in particular would be more likely to avoid buying policies.

The plan has some parallels to Medicare’s late enrollment penalty, which is applied to premiums for people who did not sign up upon turning 65. But Christopher Koller, a former Rhode Island health insurance commissioner, doubts the GOP penalty would be as effective. “Medicare is an entitlement with the force of government behind it,” said Koller, now president of the Milbank Memorial Fund, a foundation in New York that focuses on healthy populations. “You get lots of notices about what your obligations are as you approach that age.”

What about people who can’t afford premiums?

The GOP surcharge contains no hardship exemptions, unlike the individual mandate, which allowed people to escape paying a penalty if premiums would have eaten up too much of their income (8.16 percent in 2017).

In 2015, 5.6 million people paid the individual mandate penalty, but another 11 million claimed a hardship exemption, according to the IRS.

Lower-income people are going to have even more trouble buying — and keeping — coverage under the GOP plan, experts said. The ACA’s premium subsidies are based on income, and millions of people on the poorer end of the spectrum do not have to pay anything for premiums if they choose the cheapest plan. The GOP plan would offer a flat tax credit that adjusts only for age. The penalties would make some even more reluctant to buy insurance — especially if they are relatively healthy.

“I think we would just end up with a lot more uninsured people, and they would clearly be the type of people who are less able to navigate and less able to afford insurance,” said Geoffrey Joyce, director of health policy for the University of Southern California Schaeffer Center for Health Policy & Economics.

Republican lawmakers say their plan rightly places the responsibility on individuals. It is a view shared by some health insurance brokers like Helena Ruffin, a broker in Playa Vista, Calif. She said that a continuous coverage requirement would “limit those people who are not playing by the rules.”

“I am favor of the penalties,” she said. “Whether or not people are going to pay attention is another story.”

Photo: YinYang, Getty Images

Texas Medicaid payment reform initiative curbs elective early deliveries

Even though the health risks to babies born before they reach full term at 39 weeks have long been recognized, nearly 1 in 10 babies in the United States is born prematurely. Texas decided to try to change that.

In 2011, the Texas Medicaid program was the first in the country to take steps to curb elective early deliveries by refusing to pay providers who induced early labor or performed a cesarean section that wasn’t medically necessary before 39 weeks. In the first two years after that, Texas reduced the rate of unnecessary early delivery by as much as 14 percent. The state’s efforts also led to an increase in the length of pregnancies by nearly a week, with infants weighing on average nearly half a pound more, a new study found.

Those reimbursement changes were part of a Texas Medicaid payment reform law. Before it took effect, 10.63 percent of Medicaid single births in the state were early elective deliveries, according to the study, which was published in the March issue of Health Affairs.  After the law passed, the percentage of unnecessary early deliveries declined 2.03 percentage points.

About half of the decline was due to the payment reforms, while the rest could be attributed to other efforts to reduce early deliveries, unrelated trends and the economy, said Heather Dahlen, a research associate at Medica Research Institute in Minnetonka, Minnesota, and the study’s lead author.

Still, “in order for the rate to fall that much, there was a relatively significant effect on the target population,” Dahlen said.

The impact on early elective delivery was greatest for Latinos, whose rate declined 1.77 percentage points to 8.14 percent. The rate for non-Latino blacks declined 1.4 percentage points to 9.57 percent, while non-Latino whites saw a much smaller decline — 0.72 percentage point, to 8.43 percent.

Infants born before 39 weeks are more likely to have a range of health problems, including respiratory disorders, sepsis and feeding issues, and to be admitted to hospital neonatal intensive care units. Doctors and expectant mothers who opt for early delivery may not realize the risk or choose to go ahead for convenience. In some rural areas, women may be encouraged to schedule early deliveries to ensure they’re able to get to the hospital in time.

For the study, researchers analyzed data from 2009 to 2013 on the national Vital Statistics System’s Natality Detail Files, which is derived from information reported on birth certificates.

The federal-state Medicaid program for low-income people pays for roughly half of all births in the United States. After Texas passed its law, five other states passed similar laws in 2013: Georgia, Michigan, New Mexico, New York and South Carolina.

Reducing preterm births generally, and early elective deliveries in particular, is a priority for many groups, including health care providers, hospitals and patient-advocacy organizations. In addition to payment reform, these groups have employed other strategies such as educational programs for health care providers and patients and “hard-stop” policies that prohibit doctors from scheduling early elective deliveries unless they meet medical necessity standards.

“The Medicaid program was paying doctors for doing things that actually harm babies,” said Dr. Paul Jarris, chief medical officer at the March of Dimes, which publishes an annual report card that ranks states based on their preterm birth rates. “These payment changes actually make huge differences if they’re done right.”

Photo: Bigstock