There probably wouldn’t have been a more challenging time for a new government to assume office than the one faced by the Biden administration when it came to power in January. The US was in the midst of the biggest health crisis in its history, and President Joe Biden had his task cut out for him. Within hours of stepping into the Oval Office, he signed a series of Executive Orders with a focus on strengthening the Affordable Care Act (ACA).
The ACA has not just allowed greater access to care but also narrowed racial and ethnic coverage disparities. Amendments to the Act with the change of guard at the White House are not new. According to an analysis by The Commonwealth Fund, a private US foundation, healthcare stakeholders offered a range of recommendations to the Biden administration on ways to enhance the ACA and the Medicaid program.
The stakeholders include a coalition of 33 patient advocacy organizations, Families USA, the Center on Budget and Policy Priorities, the Association for Community Affiliated Plans, the Federation of American Hospitals, the Catholic Health Association of the United States, the American College of Physicians, the State Health Exchange Leadership Network of the National Academy for State Health Policy (on behalf of 17 state marketplaces), and 11 state insurance commissioners.
The analysis found that all but one of the recommendations (made before the enactment of the American Rescue Plan Act) call for reversing Trump-era policies. It said the administration has already heeded some of these calls, particularly in making operational changes that do not require new rulemaking.
Let’s have a look at the top recommendations, which offer a framework for the government to adopt policies consistent with its healthcare targets.
1. Improving Access to Coverage
The key recommendation was the need for greater federal investment in marketing, outreach, and enrollment assistance; a COVID-19 emergency enrollment period; and reverse funding cuts and regulatory changes to the navigator program. The administration has already implemented such policies. They also called for increased oversight of direct enrollment (DE) entities. The state insurance commissioners noted that expanded DE could undermine the core goals of the ACA by providing incomplete information about coverage options to consumers and failing to coordinate with state Medicaid programs. The Biden administration was also advised to rescind guidance and waivers that allow states to impose work or community engagement requirements on Medicaid beneficiaries. Emphasis is also given on the need to reverse other Medicaid waivers related to block grants, premiums, and lockouts, the analysis found.
2. Improving Affordability of Coverage
Call for fixing the “family glitch” and reversing the methodology for calculating the premium adjustment percentage is going stronger. Legislation has been introduced, but not enacted, to address these issues. The analysis said the “family glitch” stems from an Obama-era interpretation of whether an offer of job-based coverage is “affordable” or not. Currently, the definition of “affordable” for both an individual
employee and their family is based on the cost of individual-only coverage. The premium adjustment percentage is a measure of premium growth that helps determine how much individuals must contribute to premiums and out-of-pocket costs. The Trump administration altered this methodology in a way that increased premiums and out-of-pocket costs for millions of consumers.
3. Improving Adequacy of Coverage
There has been a high pitch for reversing Trump-era rules on short-term health plans and association health plans. The Biden administration is urged to address other insurance products that are exempt from ACA protections. Short-term plans do not have to meet the ACA’s requirements. They have significant benefit gaps that make these policies less expensive. The Obama administration limited the sale of short-term plans to those that cover only three months. The Trump administration revised that rule to allow short-term plans to provide coverage for up to one year and be renewed for up to three years.
If one goes by the analysis, the association health plan rule enabled sole proprietors and small businesses to enroll in large-group coverage that is not subject to the same protections that apply in the individual and small-group health insurance markets. Most of the rule’s provisions were invalidated by a district court judge.
4. Promoting Health Equity
There is a growing demand for reversing the “public charge” rule which discouraged immigrants from enrolling in certain public programs, such as Medicaid, even when eligible. The Supreme Court was scheduled to hear some of the challenges to the public charge rule, but the Biden administration settled the lawsuits, leading to dismissal. The US Department of Homeland Security then formally rescinded the rule. The stakeholders also recommended reversing changes made by the Trump administration to implement Section 1557 of the ACA, the law’s primary nondiscrimination provision. The Trump-era rule eliminated certain language-access requirements and explicit protections for LGBT patients, among many other changes.
5. Allowing Greater State Flexibility
Many stakeholders recommended rescinding the current approach to state innovation waivers under Section 1332 of the ACA and called for additional flexibility in the use of Section 1332 waivers. The Trump administration replaced Obama-era guidance with its own interpretation of Section 1332 that was criticized as legally unsound. That interpretation was ultimately adopted in regulations.
Conclusion: Affordable care and health equity is the need of the hour. The new President has the opportunity to allow the ACA and Medicaid benefits to reach a wider population using its executive authority. The Biden administration’s resolve to use its executive authority to make marketplace coverage and Medicaid more accessible enjoys broad support from a diverse group of healthcare stakeholders.
