YEAR-END REPORT - 2019 Published 23-Dec-2019 HPTS Issue Brief 12-23-19.16 Health Policy Tracking Service - Issue Briefs Healthcare Reform Insurance Market Reform Authored by a contributing writer. 12/23/2019 Introduction Enrollment in health insurance plans through HealthCare.gov fell slightly to approximately 8.5 million people by the Dec. 15 deadline. According to the Centers for Medicare and Medicaid Services, 22,599 West Virginia residents enrolled in health insurance plans via the exchange for 2019, which is fewer than the 27,000 who enrolled last year. CMS released a proposed rule that would decrease user fees for the Affordable Care Act exchanges and address the issue of “silver- loading.” Enrollment in West Virginia's health insurance exchange has continued to decline for 2019 plans. Exchange coverage between Anthem Blue Cross and Blue Shield and WellStar Health System in Georgia ended over a contract dispute. Idaho expects enrollment in its health insurance exchange to decrease by 20 percent due to the expansion of eligibility for Medicaid in the state. Legislation is pending in Montana that would give people who purchase health insurance plans on the individual market tax credits to help cover the cost of their plans. Legislation pending in Colorado is aimed at decreasing the cost of insurance policies available through the state's health insurance exchange. A recent Kaiser Family Foundation report indicated that older middle-class adult healthcare consumers pay the most for Affordable Care Act plans through the exchanges when they do not qualify for federal subsidies. Due to high out-of-pocket expenses, people in Ohio with ACA plans subsidized by federal tax credits often find healthcare unaffordable. The Vermont House preliminarily approved a bill that would significantly impair association health plans, a new type of insurance aimed at small businesses. New Jersey Governor Phil Murphy announced that the state would move to create a state-based health insurance exchange and move from the federal health insurance exchange for 2021. CMS recently finalized a rule that addresses out-of-pocket costs by allowing insurers to implement copay accumulator programs to prevent drug manufacturer coupons from applying to a patient's annual limit of costs, and a rule that will decrease exchange user fees. The Colorado Senate agreed to part of Democratic Gob. Jared Polis' plan for health care in the state by tentatively endorsing a study examining the creation of a state-run health insurance option. The Washington State Legislature passed a bill April 27, 2019 that would create a public option for health insurance. Washington's Health Benefit Exchange would offer the plan option. A new report about Oregon's health insurance exchange showed that policy changes by the Trump administration have increased health insurance premiums and destabilized the market. Maryland's two health insurance carriers requested rates showing that the cost of plans available through the state's exchange are likely to stabilize next year. © 2020 Thomson Reuters. No claim to original U.S. Government Works. -1- Gov. Jay Inslee, a Democrat, signed a bill into law in Washington that will offer a public health insurance option through the state's health insurance exchange. Colorado Gov. Jared Polis signed a bill into law that will require two state departments to develop a proposal for a public option for health care coverage available for residents to purchase through the state's health insurance exchange, Connect for Health Colorado. Connecticut legislators released a new expanded version of the bill that would create a public health insurance option in the state. The Trump Administration implemented a final regulation that will allow employers to use funds from health reimbursement arrangements (HRSs) to purchase health insurance plans. Pennsylvania will switch from the federally run health insurance exchange to its own state-run health insurance exchange where health insurers will offer Affordable Care Act-compliant plans to consumers. Health insurance premiums through the Colorado health insurance exchange in southwest Colorado could decrease by an average of 30%. The health insurance exchange in California announced that the average cost of premiums will increase by only 0.8 percent in 2020 for individual health insurance plans. This rate increase is the lowest since the health insurance exchange opened in 2013. North Dakota received federal approval of a program that will provide reinsurance for health insurance companies offering plans in the state. Colorado Gov. Jared Polis announced that the federal government approved the program for reinsurance that will help to lower the cost of health insurance premiums for consumers living in the state. The Centers for Medicare & Medicaid Services (CMS) announced that it will require ratings based on a five-star Quality Rating System nationwide for health insurance plans available through the Health Insurance Exchanges beginning with the 2020 open enrollment period. Georgia Gov. Brian Kemp announced that Georgia Farm Bureau and Anthem Blue Cross Blue Shield will offer health insurance plans outside of the state's health insurance exchange. Seven years after the launch of health insurance exchanges created under the Affordable Care Act, only eleven states and Washington, D.C. run their own exchanges. Now, six states are returning to state-run exchanges or considering a return. The cost of health insurance through Delaware's health insurance exchange is expected to decrease an average of 19 percent in 2020. Colorado officials revealed that insurance premiums for 2020 are set to decrease by an average of twenty percent throughout the state. Some residents of rural areas of the state will see even higher reductions in the cost of their health insurance premiums. Georgetown University Health Policy Institute's Center on Health Insurance Reforms (CHIR) released a report showing that the states contemplating leaving the federal health insurance exchange to create their own state-run exchanges are motivated largely by potential cost savings. Georgia Gov. Brian Kemp released waiver proposals aimed at completely changing the individual health insurance market in the state. The requested waivers are intended to help lower premiums and lessen federal control over health insurance exchanges. The Centers for Medicare & Medicaid Services indicated that the average premium for a benchmark silver plan available through HealthCare.gov fell by 4% for 2020 coverage. However, many people still find the cost of unsubsidized individual health insurance plans too expensive. In Idaho, open enrollment for plans available through the Affordable Care Act health insurance exchange began on November 1 and will continue to December 16. Idaho residents currently enrolled in exchange plans who will be eligible for Medicaid in 2020 will be automatically enrolled in the program. The Centers for Medicare & Medicaid Services released enrollment numbers for the first weeks of open enrollment for health insurance plans available through the federal health insurance exchange for 2020, showing that enrollment was less than it was during the same period last year. Enrollment Falls Slightly for Federal Exchange Enrollment in health insurance plans through HealthCare.gov fell slightly to approximately 8.5 million people by the Dec. 15 deadline. About 367,000 fewer people signed up for plans during the open enrollment season than they did last year. The numbers declined by about 4 percent. “We should have seen modest growth this year at the very least,” stated Josh Dorner, of the advocacy group Get America Covered. “But in practice we faced severe headwinds because of a number of decisions made by the Trump administrations, as well as the calamitous Texas ruling on the eve of the final day of enrollment.” Dorner was referring to a judge's ruling that the Affordable Care Act is unconstitutional. According to HHS, the law will still be enforced throughout the appeal of that ruling. © 2020 Thomson Reuters. No claim to original U.S. Government Works. -2- The final numbers of people who are covered through the individual market compared with last year will not be available until the number of people who let their policies renew automatically is counted. Also, some states have enrollment deadlines that are later than the federal deadline. Enrollment in the individual market was slower than it was in prior years. At the end of the open enrollment period, just over 4.1 million people had picked health plans through HealthCare.gov. The Centers for Medicare and Medicaid Services (CMS) operates the website. Those numbers were about half a million fewer than during the comparable period last year, according to advocacy group Protect Our Care. “I hate to panic but I do think we're going to come in low on the federal exchange, ” indicated Rosemarie Day, CEO of Day Health Strategies, the former founding COO of Massachusetts' state exchange. Day placed the blame for the lower enrollment numbers on the Trump Administration's decision to significantly cut the advertising budget for the open enrollment period. “The individual market is very, very volatile — because people are in and out of needing that kind of coverage,” Day stated. “There's always potential for new customers who may have really never paid that much attention to the exchange, because it wasn't something that they needed. It wasn't really on their radar until they did need it.” CMS asserted that it advertised on local TV and radio as well as print media. They also sent over 600 million emails and text messages about the open enrollment period. Administrator Seema Verma was also active on Twitter about enrollment. Lower enrollment numbers might not mean that fewer people will have access to health insurance coverage this year. According to Katherine Baicker, an economist and dean of the University of Chicago's Harris School of Public Policy, some policy changes from the Trump Administration, such as eliminating the individual mandate, could lead to less enrollment in health insurance plans. However, with the lower unemployment rate—from 4.1 percent to 3.7 percent—more people could be accessing health insurance coverage through their jobs. In Virginia, the state expanded eligibility for Medicaid in 2018, allowing more adults to qualify for government-subsidized health insurance coverage. About 140,000 Virginia residents had already enrolled in Medicaid. Virginia's Secretary of Health and Human Services Daniel Carey expects that number to double eventually. Some of those people mostly likely had coverage through exchange plans. About 70,000 fewer people in Virginia signed up for [FN1] exchange plans for 2019. Enrollment in West Virginia Falls for Exchange Plans According to the Centers for Medicare and Medicaid Services, 22,599 West Virginia residents enrolled in health insurance plans via the exchange for 2019, which is fewer than the 27,000 who enrolled last year. Enrollment continued to fall throughout prior years. Jeremy Smith, outreach coordinator for First Choice Services and project director for West Virginia Navigator, indicated that the enrollment numbers were expected. “We saw the trend all through open enrollment that not quite as many people were coming to enroll this year, so I think it's kind of what we feared,” Smith noted. West Virginia residents expressed concerns about the cost of plans, in particular the cost of deductibles. “A lot of people just thought that the deductibles were too high and then, where there is no penalty for not having health insurance this year, a lot of people decided to roll the dice and go without health insurance.” Smith also considered the effect of lower unemployment on the reduced enrollment numbers, with more people presumably obtaining coverage through their employers. With lower unemployment, “There is a sizable chunk of people that's been able to gain access to health insurance through an employer, so I think a lot of folks were able to transition off of the marketplace onto an employer plan,” Smith asserted. “Then there's also a constant shift between Medicaid and the marketplace, so it could just be right now that a lot of people are qualifying for Medicaid and then, in the middle of the year, their income may change and they may go back onto the marketplace.” According to CMS, 8.4 people chose plans through the exchange or automatically renewed current exchange coverage throughout the [FN2] United States. In 2018, 8.7 million people enrolled or renewed individual health insurance plans through the exchange. CMS Proposal Addresses Exchange Fees, Silver-Loading CMS released a proposed rule that would decrease user fees for the Affordable Care Act exchanges and address the issue of “silver- loading.” © 2020 Thomson Reuters. No claim to original U.S. Government Works. -3- The proposal is a notice of benefit and payment parameters for ACA exchanges in 2020. It would decrease the user fee charged to health insurers that helps to fund health insurance changes. CMS asserted that this move will help to lower the cost of premiums in 2020. According to CMS, the Trump administration is in favor of legislation that would fund cost-sharing reduction payments again. The administration halted those payments to insurers in 2017. The Trump administration also favors ending the practice of “silver-loading.” Health insurers increased the cost of silver-level health insurance plans to help cover their overall costs. Federal tax subsidies are available to people with incomes below 400% of the federal poverty level for silver-level plans, so the federal government covered most of those increased costs. Insurer began silver-loading to help cover the costs of the CSR payments that the Trump administration ended. CMS asked stakeholders to comment on solutions for addressing silver-loading. The agency wants to release rules on this issue after 2021. The 331-page notice includes proposals aimed at reducing regulation on insurers and reducing costs for consumers. “Following the first-ever drop in premiums for plans sold on the federal exchange for 2019, in another first CMS is proposing to reduce the exchange user fee charged to insurers to fund exchange operations,” CMS Administrator Seema Verma stated. “Reducing this user fee will reduce the premium each consumer pays in 2020. Under President Trump's leadership, we're finally moving the exchange and the market in a new and positive direction.” In 2020, the exchange user fee would be reduced to 3% from 3.5% of the cost of premiums through the federal exchange and to 2.5% from 3.0% for plans available through the state-run exchanges. CMS also proposed allowing individuals and families to qualify for a special enrollment period if their household income decreases to a level that makes them eligible for a federal subsidy through the exchange. Another proposal would require insurers offering plans through the exchange that cover abortion services to also offer otherwise identical plans that do not cover abortion services. The proposal would also increase the limits on annual cost-sharing that fall on consumers by 3.8% to $8,200 from $7,900 in 2020 for individual coverage, and $16,400 from $15,800 for family coverage. CMS also proposed requiring more transparency from insurers, such as requiring them to inform consumers of anticipated costs for [FN3] services. West Virginia Exchange Enrollment Declines Enrollment in West Virginia's health insurance exchange has continued to decline for 2019 plans. According to the Centers for Medicare and Medicaid Services, 22,599 people in West Virginia chose plans through the exchange. In 2018, 27,000 people enrolled in plans, a number that was less than enrollment in prior years. Jeremy Smith, outreach coordinator for First Choice Services and project director for West Virginia Navigator, noted, “We saw the trend all through open enrollment that not quite as many people were coming to enroll this year, so I think it's kind of what we feared.” Consumers were concerned about the cost of plans, particularly the cost of deductibles. “A lot of people just thought that the deductibles were too high and then, where there is no penalty for not having health insurance this year, a lot of people decided to roll the dice and go without health insurance,” said Smith. This enrollment period is the first since Congress eliminated the health insurance mandate implemented under the Affordable Care Act, requiring people to obtain health insurance or face a tax penalty. However, Smith did not think that the elimination of the mandate accounted for everyone who opted out of purchasing health insurance. Due to low unemployment, “There is a sizable chunk of people that's been able to gain access to health insurance through an employer, so I think a lot of folks were able to transition off of the marketplace onto an employer plan,” Smith indicated. “Then there's also a constant shift between Medicaid and the marketplace, so it could just be right now that a lot of people are qualifying for Medicaid and then, in the middle of the year, their income may change and they may go back onto the marketplace.” West Virginia, along with 38 other states, uses the federal health care exchange platform. West Virginia residents who are eligible for federal tax subsidies to help cover the cost of their health insurance can access those subsidies through the exchange. Open enrollment in plans available through the exchange is now closed for 2019. Some people may qualify for a special enrollment period due to circumstances such as changing jobs, income adjustments changing eligibility in Medicare and Medicaid, or changes in [FN4] group health plan coverage. Idaho Exchange Enrollment Expected to Decrease Due to Medicaid Expansion Idaho expects enrollment in its health insurance exchange to decrease by 20 percent due to the expansion of eligibility for Medicaid in the state. © 2020 Thomson Reuters. No claim to original U.S. Government Works. -4- Approximately 18,000 of Your Health Idaho's enrollees earn between 100 and 138 percent of the federal poverty level, according to Pat Kelly, the Idaho health insurance exchange's executive director. After Medicaid expansion in Idaho on Jan. 1, 2020, those people will not qualify for tax subsidies to help purchase health insurance coverage through the exchange. They will most likely enroll in coverage through Medicaid. The loss of those consumers on the insurance exchange will likely lead to a lower cash reserve for the exchange in 2020. By 2021, Kelly expects the exchange's finances to stabilize. “We've planned for this,” he indicated. “And we have sufficient net operating income to absorb the loss.” Under the Affordable Care Act, all states were meant to expand Medicaid eligibility to people making up to 138 percent of the federal poverty level. Tax subsidies for exchange coverage were supposed to be for people making more than that income level. After a 2012 United States Supreme Court ruling, Medicaid expansion became optional for the states. The federal government subsequently extended the tax subsidies to people making less than 138 percent of the federal poverty level if they did not qualify for Medicaid because their states opted out of expansion. Last November, Idaho voters approved Medicaid expansion. Gov. Brad Little requested federal funding to expand the program. [FN5] A lawsuit challenging Medicaid expansion filed by the Idaho Freedom Foundation is currently pending. Contract Dispute Affects Georgia Exchange Customers Exchange coverage between Anthem Blue Cross and Blue Shield and WellStar Health System in Georgia ended over a contract dispute. Anthem is allowing consumers in the Georgia insurance exchange more time to visit physicians in WellStar Health System without increased out-of-pocket costs. The insurance company will allow current exchange customers to access network coverage at WellStar for 90 days if they currently have a WellStar primary care physician. Thousands of Georgia residents, many from the Atlanta area, are affected by the contract dispute. In a statement, Anthem indicated that some Georgia consumers “may have enrolled in Anthem plans based on the incorrect assumption WellStar would remain in our Pathway network throughout 2019.‘’ According to WellStar, based in Indianapolis, it has worked with Georgia Insurance Commissioner Jim Beck to extend WellStar coverage. Anthem will allow previously contracted reimbursement rates for physicians, but it “cannot guarantee WellStar will permit Pathway members to schedule appointments, or will not bill members for the difference between the Anthem allowed reimbursement and WellStar's billed charges.‘’ Consumers have already complained about WellStar leaving the Anthem exchange coverage network since it was listed as part of the network when they signed up during the open enrollment period last year. According to Chris Kane, a consultant for Progressive Healthcare, “Although formal notices of contract termination are frequently part of the negotiation dance, enrollees are increasingly skittish about disruptions to their health care.” WellStar has 11 hospitals. Several of them are in Cobb County and other suburbs northwest of Atlanta, where the contract dispute will have the largest impact. ”We look forward to ensuring our members receive high-quality, affordable care through our network of participating providers and hospitals,” Anthem stated. “Consumers with questions can call the number on the back of their Anthem ID card or go to anthem.com/ wellstar.” Kane indicated that contract disputes between insurers and health care providers can significantly affect consumers. “In recent years, Anthem/Blue Cross has engaged in high-profile negotiations with Grady and Piedmont,‘’ Kane stated. “Although formal notices of contract termination are frequently part of the negotiation dance, enrollees are increasingly skittish about disruptions to their [FN6] health care.” Colorado Bill Would Lower Exchange Insurance Costs Legislation pending in Colorado is aimed at decreasing the cost of insurance policies available through the state's health insurance exchange. The Colorado exchange is known as Connect for Health Colorado. House Bill 1168 would create a reinsurance program that would decrease the cost of premiums by 30 to 35 percent in the Western Slope area of the state. It would also create savings for customers in other areas of the state. © 2020 Thomson Reuters. No claim to original U.S. Government Works. -5- Health analysts are optimistic about the bill's changes at becoming law since it has the support of Gov. Jared Polis and senior Democrats. ”It's an important idea to try to stabilize and lower the premium costs as quickly as we can,” stated Adam Fox, director of strategic engagement at the Colorado Consumer Health Initiative. Fox noted that another bill is pending that would create a public option for health insurance in Colorado, but that plan would probably take more time. The reinsurance program would allow insurance companies to access a fund to cover the cost of large claims from beneficiaries. The plan would offer some financial security for insurance companies, resulting in lower premiums for consumers, according to Joe Hanel, spokesman for the Colorado Health Institute. The draft legislation would allow the Division of Insurance to decide how much insurance companies would have to pay before accessing the reinsurance fund. The department would also decide how much medical providers would receive for health care bills covered by the reinsurance fund. The bill would direct the state to apply for federal funding to cover the cost of the reinsurance fund. Hanel noted that the federal government has given funding to other states for similar programs. Hanel suggested that the federal funding could come from funding for individual tax credits since people who qualify for the tax credits would benefit from the savings from reinsurance program, as well as those who do not qualify for the credits. “It's a way of spreading the wealth of the tax credits to the people who don't qualify,” he indicated. Vincent Plymell, a spokesman for the Division of Insurance stated that more study is needed to determine the exact level of savings for [FN7] consumers from a reinsurance program. Montana Bill: Tax Credits for Insurance Coverage Legislation is pending in Montana that would give people who purchase health insurance plans on the individual market tax credits to help cover the cost of their plans. Sen. Albert Olszewski, a Republican from the Flathead introduced the bill. Olszewski, who ran in his party's primary for U.S. Senate last year, pointed to the cost of health care and the cost of health insurance as the top concerns from people on the campaign trail. The Affordable Care Act allowed states to create health insurance exchanges where their residents can purchase health insurance coverage. Residents of states that chose not to set up their own exchanges can access the federal health insurance exchange. People who cannot obtain insurance from their employers can buy individual plans through the exchange. Approximately 45,700 Montana residents purchased health insurance plans through the exchange for 2019. Approximately 88 percent of those people are eligible for federal tax credits to help cover the cost of their premiums. People earning up to 400 percent of the federal poverty level, or $48,560 for an individual or $100,400 for a household of four are eligible for the federal credit. Under Olszewski's bill, everyone who purchase health insurance plans through the exchange would qualify for the Montana tax credit. However, the people who do not qualify for the federal tax credit would benefit the most. The exact amount of the state tax credits under the bill is not certain yet, but they would max out at the average Medicaid expenditure per person or the total cost of the premium. According to a fiscal note on the fill, $3,292 is the maximum amount a person could claim under the bill. The average monthly cost of a health insurance plan in Montana with the current federal tax credits is $183, or $2,196 a year. People who do not qualify for the federal tax credit, costs can range from $240 to over $1,700 per month, depending on the type of plan, region, and the age of the consumer. Olszewski asserted that the bill would give people equity who purchase exchange plans and don't receive tax credits, even though their tax dollars help cover the cost of Medicaid expansion in the state. He also indicated that the legislation could help people who are now covered through Medicaid if the state chooses not to extend [FN8] expansion of the program beyond the summer, when it is scheduled to expire without legislative action. Report: Older Middleclass Consumers Pay Most for ACA Plans A recent Kaiser Family Foundation report indicated that older middle-class adult healthcare consumers pay the most for Affordable Care Act plans through the exchanges when they do not qualify for federal subsidies. People living in rural areas were particularly affected. © 2020 Thomson Reuters. No claim to original U.S. Government Works. -6- Researchers studied the cost of bronze ACA marketplace plans and found that rural counties in Nebraska had the most expensive plans for middle-aged adults who did not qualify for subsidies. In Lincoln County, Nebraska, a 60-year-old person making $50,000 could purchase a plan for $1,314, which is 32% of income. A person in the same county making $45,000 would not owe a monthly premium because they qualify for the federal subsidy. According to the study, in 21% of counties throughout the United States, a 40-year-old making $50,000 per year spends over 10% of income on the least expensive ACA coverage. These numbers differ between urban and rural areas. In rural areas, the cost of plans in 25% of counties for similar age groups is over 10% of income. In metropolitan areas, only 5% of counties have similar prices. Researchers pointed to the subsidy cliff, where the federal subsidy ends at 400% of the federal poverty level, as problematic for people earning only a few thousand dollars more than their peers. They end up paying significantly more for coverage. Under the ACA, insurance companies can charge up to three times higher for older people based on age. The increased prices disproportionately affect older people who make too much to qualify for the federal subsidy. Rural areas such as Wyoming particularly experience this effect. Wyoming has the highest average premium for middle-class people who do not qualify for subsidies. The state with the lowest average premium for this group is Rhode Island. The cost of premiums through the ACA exchanges have stabilized overall, with only small increases in costs in 2019. Even so, the cost of unsubsidized plans available through the ACA is still high. The ACA has expanded affordable coverage for Americans with lower incomes who qualify for federal subsidies or expanded Medicaid coverage. However, middle-class and upper-middle-class people are still having trouble finding affordable coverage. The Trump administration expanded access to low-cost short-term plans, but the coverage from those plans is limited and can result in significant out-of-pocket costs if beneficiaries need to use the plans. The availability of those cheaper plans will also potentially lead to fewer healthy people participating in the ACA exchange plans, driving up the cost of those plans. Researchers pointed to the expansion of premium tax credits as a possible solution. In California, recently proposed tax credits would be available to people making up to 600% of the federal poverty level. An individual making up to $72,840 would qualify. “So far, while there seems to be a consensus that individual market premiums are out of reach for some middle-class people ineligible [FN9] for ACA subsidies, there is little consensus around what to do about it,” researchers stated. ACA Plan Beneficiaries Face High Out-of-Pocket Costs Due to high out-of-pocket expenses, people in Ohio with ACA plans subsidized by federal tax credits often find healthcare unaffordable. Researchers at Case Western Reserve University School of Medicine recently released a study of the issue. They collected data from almost 43,000 Ohio adults. Low- to middle-income adults who received subsidies to help cover the cost of premiums through the ACA health insurance exchange were significantly more likely to have trouble accessing and affording healthcare when they needed it. The data revealed a frequent occurrence of skipping doctor's visits and failing to fill prescriptions when compared with people who received coverage under Medicaid due to expanded eligibility. “High out-of-pocket costs associated with exchange health plans often mean that those who don't qualify for Medicaid face significant barriers to accessing affordable care,” stated the study's senior author, Siran Koroukian, PhD, associate professor in the Department of Population and Quantitative Health Sciences. “As a result, they delay or omit needed care; and the likely scenario is that they become sicker before they eventually qualify for Medicaid. This creates a paradox: they formally have insurance, but because they can't afford the high deductibles and co-pays, they may be worse off medically than those without insurance or who receive Medicaid, which has nominal co-expenses.” The study is available in the Journal of General Internal Medicine. Researchers looked at accessibility and affordability between Medicaid recipients in Ohio and Ohio residents who qualified for federal tax subsidies to purchase coverage through the ACA exchange. Researchers found that people covered by subsidized exchange plans were: 2.5 times more likely to have difficulty paying medical bills 2 times more likely to have foregone needed medical exams or supplies 2 times more likely to have skipped filling a prescription because of high cost 2 times more likely to have had a harder time getting medical care than in the past 1.75 times more likely to avoid needed medical care “We know that ACA has insured more people, which was its intent, but there is work to be done in making that insurance more effective in getting care for low- and middle-income people,” indicated the study's lead author, Uriel Kim, an MD/PhD student in the School © 2020 Thomson Reuters. No claim to original U.S. Government Works. -7- of Medicine. “Typically we think of Medicaid recipients as more vulnerable than those with private insurance. But in reality, Medicaid expansion has gone well because it is meeting its goal of increasing access to affordable care for its users. At the same time, relatively high out-of-pocket expenses mean that some recipients who use exchanges are choosing to go without care, which in the long run [FN10] makes them sicker - even having to turn to Medicaid to get the care they need.” NJ to Create State-Run Exchange New Jersey Governor Phil Murphy announced that the state would move to create a state-based health insurance exchange and move from the federal health insurance exchange for 2021. The move will give New Jersey greater control over the health insurance market in the state. It will also give the state the opportunity to create stronger protections for consumers in the face of the Trump administration's continued campaign to weaken and eliminate the Affordable Care Act. Gov. Murphy also proposed passing state laws aimed at keeping the current protections of the Affordable Care Act for New Jersey residents. “New Jersey has not shied away from the work required to secure the protections afforded by the Affordable Care Act and to provide access to quality affordable health care that our residents deserve – in fact, in partnership with the Legislature our state has stepped up,” said Governor Phil Murphy. “Together with the Legislature, we have the ability to further protect New Jersey from actions taken by the Trump Administration to roll back the hard-fought protections afforded by the ACA and I would argue we have an obligation to do so.” “New Jersey's work has demonstrated results for consumers and created greater access to quality affordable coverage. However, because we are operating on the federal exchange, we are subject to the whims of the Trump administration and directly impacted by its efforts to damage and destabilize the market,” said Department of Banking and Insurance Commissioner Marlene Caride. “Moving to a state-based exchange is the right next step in our work to improve access to coverage and care. The federal government has cut the enrollment period, and slashed funding for outreach, advertising and navigators that provide critical assistance to residents in our communities. Funding sent to Washington to utilize the federal exchange will be better utilized right here in New Jersey, where we can establish policies that create greater stability, access and improved protections for residents.” The decision was aimed at ensuring the New Jersey residents will continue to access affordable health insurance coverage options through the individual market and the small employer market. Governor Murphy expressed concern over the Trump administration's threats to the ACA, asserting that “it is vital that the state build upon the progress made through the Affordable Care Act. New Jersey has already taken significant action to stabilize the market – it established a reinsurance program, implemented a requirement to have coverage, and took over plan management of the exchange in New Jersey.” Due to these actions, the cost of premiums on the individual market decreased by 9.3 percent this year. “Maintaining a viable insurance market is critical to the success of the ACA, currently being undermined and sabotaged by the Trump Administration. New Jersey has benefited immensely from the ACA and I am glad to see that we are doing what we can to maintain the benefits for New Jerseyans across the state that rely on crucial health care services,” said Senator Vitale, the chairman of the Senate Health, Human Services and Senior Citizens Committee. “In recent years, New Jersey had achieved real progress in lowering its uninsured rate and bringing down the cost of health insurance through thoughtful and creative policy decisions. So, when the federal government attempted to dismantle the Affordable Care Act, we acted swiftly to ensure that the progress made was not lost,” said Senator Troy Singleton. “However, more needs to be done to expand access to health insurance and to stabilize the marketplace. I look forward to working with [FN11] Governor Murphy and my legislative colleagues to make that happen.” Vermont Legislature Considers Association Health Plans, Insurance Mandate The Vermont House preliminarily approved a bill that would significantly impair association health plans, a new type of insurance aimed at small businesses. The bill takes an important regulatory and financial advantage from the plans. Advocates for the bill oppose the association plans, asserting that they were allowed too quickly and without oversight. The bill also addressed the forthcoming Vermont “individual mandate” requiring residents to obtain health insurance coverage. The original version of the bill included an income-based penalty in 2020. That penalty has been removed from the bill. According to George Till, D-Jericho, Ways and Means did not have the time to properly address issues related to the mandate, such as the expense and administrative trouble for collecting the penalty. “This was neither a political or philosophical decision,” Till stated. “This was purely a practical amendment to say, ‘We do not have time to do this properly, and as it stands, it isn't going to work.”’ © 2020 Thomson Reuters. No claim to original U.S. Government Works. -8- Others were concerned about the affordability provisions of the penalty. Mike Fisher, the state's chief health care advocate, indicated, “I had been in favor of a penalty that applied to people who we thought could afford health insurance. We had a difference of opinion about who could afford health insurance.” If the bill passes the Senate, Vermont will be left with an insurance mandate without a penalty or a means to enforce it. Vermont residents will still be required to report on their tax returns if they obtained health insurance coverage during the previous year, [FN12] regardless of whether there is an actual penalty. Colorado Legislation Aimed at Creating State-Run Option The Colorado Senate agreed to part of Democratic Gob. Jared Polis' plan for health care in the state by tentatively endorsing a study examining the creation of a state-run health insurance option. Under pending legislation, state agencies would recommend a plan that would compete with private health insurance plans and the plans offered through the state's health insurance exchange. The study bill will go to the governor with another vote from the Senate. The legislation passed the House with a bipartisan vote. Supporters of the bill argue that it will help with the cost of some of the highest insurance premiums in rural areas of the state. In fourteen of the state's 64 counties, only one insurer serves the individual market. Monthly premiums for health insurance plans can cost as much as $500 more than in urban areas of the state. Polis supports several measures including the “public option” bill aimed at reducing health care costs and increasing access to insurance for Colorado residents. When Polis campaigned for office, he focused on several strategies for gaining universal coverage for Colorado residents. The governor signed a hospital price transparency bill into law earlier in his term. The Democrat-majority Legislature is likely to send the governor bills that would create a state reinsurance program to help private insurers with their costliest beneficiaries, a prescription drug price transparency bill, and a bill to gain permission from the federal government to import Canadian prescription drugs. If the public option legislation passes, the Department of Health Care Policy and Financing and the Department of Regulatory Agencies would present a proposal in November. The proposal would calculate costs, point to funding sources, and identify necessary federal permissions and funding, consumer eligibility and who in the government would run the plan. Advocates for the bill indicated that enrollment could begin as early as 2020, with a plan operating in 2021. Sponsors of the bill are [FN13] Democrats Sen. Kerry Donovan and Rep. Dylan Roberts, and Republican Rep. Marc Catlin. CMS Addresses Exchange User Fees, Out-of-Pocket Drug Costs CMS recently finalized a rule that addresses out-of-pocket costs by allowing insurers to implement copay accumulator programs to prevent drug manufacturer coupons from applying to a patient's annual limit of costs, and a rule that will decrease exchange user fees. Virginia and West Virginia became the first states to ban copay accumulators on the individual market. An additional eight states are considering similar bans. Patient advocates oppose the ban, saying they limit access to medication. However, CMS is in favor of the rule, asserting that it will encourage patients to choose generic drugs at lower costs. The regulation will apply to the individual market, small group plans, large group and self-insured group health plans beginning in 2020. CMS implemented a regulation that will cut exchange user fees. The rule is aimed at lowering premiums costs. The user fee, which is currently 3.5% of premiums for qualified health plans sold via the federal exchange in 2020, will be reduced to 3%. State-based exchange plans currently have a fee of 3%. It will be reduced to 2.5%. “The rule issued today will give consumers immediate premium relief for 2020 by reducing the federal exchange user fees thanks to successful efforts to improve the efficiency of the exchange,” CMS Administrator Seema Verma indicated in the announcement. “At CMS we have improved the operations of the exchange to deliver a better consumer experience at a lower cost.” The new regulation was first proposed in January. It is part of the annual rule that sets the standards for insurers selling coverage through the ACA exchanges next year. The new regulation will also finalize a proposal that will make changes to the methodology used to calculate how much subsidized exchange enrollees must contribute toward benchmark health plan premiums. The required contribution percentage for 2020 will decrease to 8.24%. Annual out-of-pocket maximums will increase under the new regulation for people with individual health insurance plans and plans through their employers to $8,150 for single coverage and $16,300 for family coverage. These numbers are a 3.2% increase over the 2019 limits. CMS also addressed several provisions focused in improving the risk-adjustment data validation audits, giving insurers more certainty. © 2020 Thomson Reuters. No claim to original U.S. Government Works. -9- Additionally, CMS approved Alabama's request to reduce risk-adjustment transfers for the small group market in 2020. The transfers will be lowered by 50%. The final regulation also created a new special enrollment period for people enrolled in an off-exchange individual insurance plan if their household income decreases enough to make them eligible for a premium tax credit through the health insurance exchanges. In the proposed rule, CMS indicated that it is in favor of ending the practice of “silver-loading.” The agency asked stakeholders to comment on ways to address silver-loading in future regulations. CMS summarized the stakeholder comments in the final rule and noted that it will take the comments into consideration in the future. [FN14] However, it declined to finalize a rule about silver-loading at this time. Oregon Health Insurance Exchange Negatively Affected by Federal Policies A new report about Oregon's health insurance exchange showed that policy changes by the Trump administration have increased health insurance premiums and destabilized the market. OSPIRG Foundation and Frontier Group, a consumer advocacy group, issued the report. Researchers indicated that the state's health insurance exchange, which was created under the Affordable Care Act, is showing strain from recent policy changes. Without efforts to stabilize the market it could collapse. “We're not necessarily expecting that to happen in the next year or two, but there's that risk,” indicated Mark Griffith, a health care advocate with OSPIRG. “It wouldn't take a lot of disruption to get us to the point where things are potentially destabilizing.” The increasing cost of premiums is causing less healthy, middle-class people to purchase coverage through the exchange. In 2019, the average monthly cost for a mid-level silver plan through the Oregon exchange almost doubled from the 2014 cost to $443. People who qualify for federal tax subsidies under the ACA are protected from those premium increases. After subsidies, the average monthly cost for a non-smoking 40-year-old in Portland is $209 for a silver plan. Individuals making above $49,460 per year do not qualify for subsidies. Families of four making over $103,000 do not qualify. “They're not getting subsidies, but they're still not making that much money,” Griffith noted. “They're facing these very, very high premiums.” Approximately 3.7 percent of Oregon residents purchase health insurance coverage through the exchange. Five percent purchase individual health plans. Before the implementation of the ACA, consumers with pre-existing conditions often could not obtain coverage. Plans could offer limited coverage and annual or lifetime caps on benefits. The ACA eliminated many of these issues by regulating insurers. However, the average price of policies increased. Researchers pointed to several forces driving the increased cost of premiums through the exchange. In 2019, prices increased 9% on average. They found that healthcare overall is becoming more expensive due to increases in the price of services and medications as well as an increase in the quantity of services provided to patients. For both individual plans and plans paid for by employers, the average cost of health insurance is over 30% of median household incomes. In 1990, that rate was 15%. Researchers pointed to actions by Congress and the Trump administration as causing increased prices. The legislature eliminated the insurance mandate, decreased outreach and marketing to encourage people to purchase coverage, ended payments to insurance plans to reduce risk for insurers, and ended payments that helped insurers cover their most costly beneficiaries. Fewer healthy people purchased insurance, which resulted in a smaller pool of paying customers to cover the cost of sicker people needing more services. As a result, prices have increased. “I think what we've seen is that the marketplace that currently exists is a lot more stable than we expected in the absence of an insurance mandate. And that's because the population that's being covered is different from what we originally expected,” Griffith stated. “Pretty much everybody who's still on the marketplace is subsidized. The population that is not subsidized, for the most part, they're not buying insurance.” Last year, Oregon Insurance Commissioner Andrew Stolfi announced the final premiums for 2019, stating that changes from the federal [FN15] government “continue to inject instability into our market.” Washington Moves Forward on Public Option The Washington State Legislature passed a bill April 27, 2019 that would create a public option for health insurance. Washington's Health Benefit Exchange would offer the plan option. The plan, Cascade Care, would make Washington the first state to adopt a public option. Senate Bill 5526, sponsored by Sen. David Frockt (D-Seattle), and led in the state House of Representatives by Rep. Eileen Cody (D- West Seattle), would allow Washington residents who purchase individual health insurance plans through the state's health insurance exchange to choose the option, aimed at decreasing the cost of premiums, copays and other out-of-pocket expenses. © 2020 Thomson Reuters. No claim to original U.S. Government Works. -10- Gov. Jay Inslee supported the pending legislation, working with legislators throughout the creation of the bill. The bill passed with a 56-41 vote in the House, and a 27-21 vote in the Senate. The governor will next review the bill. “Under the current administration in Washington DC, health care policy has gone backwards,” Frockt stated. “Their policies have led to dramatic increases in premiums and deductibles for our residents who don't have employer sponsored coverage rely on coverage from our health benefit exchange.” Under the proposal, a standard benefit package will become available to consumers. The package is focused on ease of consumer understanding and on decreasing cost sharing such as deductibles and copays. The proposal is also meant to bring more transparency and predictability to the individual insurance market. “Cascade Care is the next step in affordable and accessible health care for everyone and further demonstrates the Democratic desire to ensure access to care. It is that dedication that has led to the state's lowest uninsured rate ever and a guarantee of essential health benefits to keep Washington families healthy,” said Rep. Eileen Cody, Chair of the House Health Care & Wellness Committee. [FN16] The plan will be available to all Washington residents regardless of income who do not have access to employer health plans. Washington Governor Signs Public Option Bill Gov. Jay Inslee, a Democrat, signed a bill into law in Washington that will offer a public health insurance option through the state's health insurance exchange. “These two bills are models for the rest of the nation to consider,” Inslee indicated. “Washington state, once again, is at the head of the pack when it comes to policies that help working families and provide much-needed security when it comes to their health care.” Washington will be the first state to offer a public option for health insurance coverage. Recently, Colorado legislators approved a bill that would direct state agencies to create a proposal for a public health coverage option. It is one of several states considering a public option. The new Washington law, known as Cascade Care, will allow the state to join with private health insurance carriers to offer three levels of plans: bronze, silver and gold. The plans will be offered in November 2020. The plans will cap provider and facility reimbursement rates at 160% of Medicare in order to keep the costs of premiums and deductibles lower. Consumers will be able to purchase the plans through the state's Health Benefit Exchange, Washington's health insurance marketplace created under the federal Affordable Care Act in 2011. Less than 3% of the population of Washington, or about 200,000 residents, purchase individual health insurance plans via the state's exchange. According to data from the exchange, enrollment in individual plans dropped by over 13,000 people between 2018 and 2019. Currently, 5.5% of Washington residents are uninsured. Health insurers can participate in Cascade Care on a voluntary basis. The public option plans are not guaranteed to be offered in all counties in Washington, even though the legislation was aimed at comprehensive coverage. Health insurers will not be required to offer statewide coverage. They will be able to bid on Cascade Care plans in single or multiple counties. The individual market in Washington has seen instability and significant premium increases for years. This year, the average premium increase approved by the Washington insurance commissioner was 13.5%. The average rate increase in 2017 was 35%. Washington state officials pointed to Trump administration policies as negatively affecting the individual insurance market. These policies include ending federal reinsurance and cost sharing payments as well as ending the individual mandate. “It's been a triple whammy that's created this bow wave effect in terms of premium increases year over year,” stated the Exchange's CEO Pam MacEwan. Legislators supported the public option to increase plan offerings through the exchange without decreasing mandates for coverage. “This is going to lower premiums, it's going to have better cost-sharing and Washingtonians will be much better off for it,” indicated the bill's prime sponsor, Democratic state Sen. David Frockt of Seattle. According to Frockt, the public option could cost up to 10% less than traditional plans offered through the exchange. [FN17] Republican legislators opposing the public option worried about unintended consequences, such as a distortion of the market. Maryland Exchange Premiums Stabilize Maryland's two health insurance carriers requested rates showing that the cost of plans available through the state's exchange are likely to stabilize next year. © 2020 Thomson Reuters. No claim to original U.S. Government Works. -11- According to state regulators, carriers and advocates, actions by the Maryland General Assembly and Gov. Larry Hogan will lead to lower costs for the nearly 200,000 Maryland residents who purchase plans through the exchange. “The initial indication is that the reinsurance program created last year by the legislature and the governor had its intended effect and we're seeing added stability in the market because of it,” stated Al Redmer Jr., state insurance commissioner. Hogan, a Republican, joined with the majority Democratic legislature to extend a tax on insurance carriers that Congress had eliminated federally. The funds from that tax are pooled to fund reinsurance that assists insurance companies in covering the most expensive claims. The rate requests must still receive approval from the Maryland Insurance Administration. A public hearing will be held in July. Premium costs will be finalized by mid-September. The larger carrier of the two carriers still offering plans through Maryland's exchange is CareFirst BlueCross BlueShield. Kaiser Permanente also offers plans. “Although these are just proposed rates, it's exciting that consumers will continue to see around the same or even a decrease in rates for the 2020 plan year,” indicated Michele Eberle, executive director of Maryland Health Benefit Exchange. “Affordability is a big [FN18] concern for all Marylanders when making a choice about health coverage.” CT Public Option Bill Expanded Connecticut legislators released a new expanded version of the bill that would create a public health insurance option in the state. The “Connecticut Option” is a state-sponsored plan that would be available to individuals and small businesses without employer- subsidized health insurance plans. To help fund the plan, the legislators proposed re-establishing the penalty for failing to obtain health insurance coverage that the federal government recently eliminated. If the mandate was implemented in Connecticut as a state tax, proponents predict it will raise $25 million per year. The bill would require the state's Office of Health Strategy to form an advisory committee consisting of experts, consumer advocates and state officials. The committee will work on network criteria, designs and provider reimbursement rates aimed at ensuring that consumers will save 20 percent compared to premium rates in 2020. The state comptroller's office will call for bids from insurers to create the Connecticut Option “as a publicly sponsored competitor” in the individual and small group health insurance markets in the state. All insurers offering plans through Connecticut's health insurance exchange will be required to offer the Connecticut Option. The implementation goal for the plan in January 2022. “It is the most ambitious health care package any state has considered. It helps those folks who are falling through the cracks,” indicated Sen. Matthew Lesser, D-Middletown. “Many of us are familiar with a usual path of legislation, which is, it starts off strong and then it gets watered down,” said Sen. Lesser, a key proponent of the bill. “I think this bill that we're talking about went the other way.” Lesser introduced the bill along with Rep. Sean Scanlon, D-Guilford. He called the legislation a “comprehensive attempt at health care reform” that would “blaze a path forward for other states to follow.” Lawmakers also considered funding the program through a 1-cent-per-milligram tax on opioid manufacturers imposed at the first point of sale, not at the retail level. The comptroller's office estimated that the tax would raise approximately $20 million per year in Connecticut. Those opposed to the tax increases on drug manufacturers argued that the cost would ultimately fall on consumers when insurance companies raise premiums to cover the cost of the tax. “It's disappointing that, despite the biopharmaceutical industry's repeated attempts to put forward solutions to lower [people's] costs at the pharmacy counter, Governor Lamont would call for unworkable changes … at the last minute,” the Pharmaceutical Research and Manufacturers of America indicated in a statement. “Putting forward a tax on medicines that meet legitimate medical needs is not an appropriate way to fund the governor's priorities that have nothing to do with the opioid crisis in Connecticut.” The legislation also includes a cap on costs for health care providers, insurers, drug manufacturers, and others in the healthcare industry. Organizations exceeding the cap would need to submit a plan for reducing costs to the state Office of Health Strategy. Sanctions beyond public exposure and legislative hearings are not included in the legislation but could be added in the future, [FN19] according to Comptroller Kevin Lembo. Colorado Governor Signs Public Option Proposal Legislation © 2020 Thomson Reuters. No claim to original U.S. Government Works. -12- Colorado Gov. Jared Polis signed a bill into law that will require two state departments to develop a proposal for a public option for health care coverage available for residents to purchase through the state's health insurance exchange, Connect for Health Colorado. Fourteen counties in Colorado have only one option for health insurance plans through the exchange. The public option health insurance could include the ability to buy-in to the state's Medicaid program. Alternatively, it could include an option to purchase coverage in the state's self-funded medical insurance program which is currently only available to state workers. The legislation was introduced by Reps. Marc Catlin, R-Montrose, Dylan Roberts, D-Avon and Sen. Kerry Donovan, D-Vail. The Colorado House supported the bill with a bipartisan vote. The Senate passed the bill 19-16 on party lines. The departments of Regulatory Agencies and Health Care Policy and Financing will need to create a proposal for the General Assembly by November. The proposal would then have to be the subject of its own bill to become law. Polis also signed a bill into law that will create a state reinsurance program for insurers offering plans through Colorado's exchange. Reinsurance helps cover the cost of the most expensive patients for insurance companies. The state program will require federal approval, but it will operate like current private reinsurance plans. “The reason I got involved in this bill in the first place is because of the high cost of health care and insurance on the Western Slope,” stated Rep. Janice Rich, R-Grand Junction, who introduced the bill with Sens. Kerry Donovan, D-Vail, and Bob Rankin, R-Carbondale, and Rep. Julie McCluskie, a Dillon Democrat whose district includes Delta County. “That was my initial interest in this bill, and it still is. [FN20] Lowering health care costs in western Colorado is very important to me, that's why I stuck it out.” PA to Create State-Run Exchange Pennsylvania will switch from the federally run health insurance exchange to its own state-run health insurance exchange where health insurers will offer Affordable Care Act-compliant plans to consumers. The plan is aimed at encouraging more people in the state to participate in the exchange and to lower the cost of plans offered. Gov. Tom Wolf signed the bill that will make the change. It passed the legislature unanimously. The Wolf administration introduced the legislation in June after gaining support for the change from many Pennsylvania businesses and consumer advocacy groups. The plan also had support from the Republican-controlled legislature prior to the introduction of the bill. The state informed the federal government of its intent to switch to a state-run exchange. Pennsylvania intends to submit plans for the state-run exchange mid-summer. The Pennsylvania exchange website will be ready next year for enrollment in plans beginning in 2021. The Wolf administration indicated that it would take over some of the marketing and outreach for Healthcare.gov in 2020. The plan will likely decrease premiums by 5% to 10% for Pennsylvania residents buying plans through the exchange. Approximately 400,000 state residents access insurance through the marketplace. According to Jessica Altman, Wolf's insurance commissioner, the savings will be particularly helpful for the 80,000 Pennsylvania residents who purchase insurance through the federal exchange but do not qualify for a tax subsidy to help cover the cost of the plans. Health care policy analysts assert that states have more control over state-run health insurance exchanges. For example, if the Trump administration ends automatic re-enrollment for plans available through healthcare.gov, Pennsylvania could choose to keep automatic re-enrollment through its own exchange, making it easier for residents to keep their plans. The Trump administration has significantly cut the marketing budget for healthcare.gov and decreased funding for navigators who assist consumers during the enrollment process for health plans. The actions have negatively affected enrollment in health insurance plans nationwide. Altman indicated that Pennsylvania will take over these duties and do better for health insurance consumers. “There's a lot of things that we can do when we have the data and we know about the people who are using this market to do it better,” she noted. The state will access information about enrollment numbers and reasons for choosing or not choosing coverage. It will be able to partner with consumer advocacy groups to increase outreach “to make that marketing about Pennsylvania, make it Pennsylvania- grown, Pennsylvania-specific, and that's going to make a difference,” Altman stated. The state will save money from taking over the exchange. It will use those savings along with extra federal reinsurance funds to reimburse insurers for the cost of covering the most expensive claims. The federal government receives 3.5% of the cost of premiums sold through the federal exchange, which amounts to about $94 million per year. [FN21] According to Wolf's administration, the state can run the exchange for $30 million to $35 million. © 2020 Thomson Reuters. No claim to original U.S. Government Works. -13- Regulation Allows Health Plan Payment through HRAs The Trump Administration implemented a final regulation that will allow employers to use funds from health reimbursement arrangements (HRSs) to purchase health insurance plans. The U.S. Departments of Health and Human Services, Labor, and the Treasury indicated that the final rule will affect about 800,000 employers and over 11 million employees and their family members, including approximately 800,000 uninsured Americans. According to HHS Secretary Alex Azar, “Too many Americans today have little say in how their healthcare is financed. President Trump has promised Americans that he will put them in control of their healthcare, and this expansion of health reimbursement arrangements will help deliver on that promise by providing Americans with more options that better meet their needs. This rule and other Administration efforts are projected to provide almost 2 million more Americans with health insurance.” “By continuing to offer diverse health coverage choices, the Trump Administration ensures America has a healthy workforce,” indicated Labor Secretary Alex Acosta. “The HRA final rule offers millions of American workers more health coverage choices and portability. HRAs create a great opportunity for job creators to support their employees and for those employees to be empowered to make the best healthcare decisions for their families.” Beginning in January 2020, employees will be able to use funds from tax-preferred individual coverage HRAs to purchase health insurance plans through the individual market. The plan is subject to several conditions intended to balance employer flexibility and adverse selection of the individual market. According to the Trump administration, the full implementation of the HRA rule, along with the Association Health Plan rule, and the short-term, limited-duration insurance rule will help 2 million uninsured people gain health insurance coverage. Using funds from an HRA to purchase an individual health insurance plan will give employees the same tax advantage as employees [FN22] with traditional employer-sponsored plans. Lowest Increase in CA Exchange Premiums to Date The health insurance exchange in California announced that the average cost of premiums will increase by only 0.8 percent in 2020 for individual health insurance plans. This rate increase is the lowest since the health insurance exchange opened in 2013. According to Peter V. Lee, the executive director of Covered California, the small increase is due to bills the California Legislature passed and Gov. Gavin Newsom signed into law over the past year. One of the new laws imposes an individual mandate requiring California residents to acquire health insurance coverage or face a state tax penalty. The law will also provide state subsidies to help cover the cost of insurance policies for about 922,000 residents. “The bold moves by Gov. Newsom and the Legislature will save Californians hundreds of millions of dollars in premiums and provide new financial assistance to middle-income Californians, which will help people get covered and stay covered,” Lee said via a prepared news release. “California is building on the success of the Affordable Care Act and bringing quality care and coverage within reach for more people.” According to Lee, the legislative changes led to improved confidence among insurers in the state and encouraged a major national insurance company, Anthem Blue Cross, to return to a large portion of the state. Upon hearing about the 0.8 percent average increase in premiums, state Richard Pan, D-Sacramento, asserted, “That's less than inflation. Think about that.” Consumer advocate Anthony Wright with Health Access California was in favor of the low increase and pointed to it as proof that state policies aimed at defending the Affordable Care Act were working. Consumer advocates, academic experts and health insurers were in favor of the individual mandate in California and other changes focused on improving the affordability of health insurance. “As a result of state actions, most Covered California enrollees will pay less for health insurance, as a lower percent of their income, than they do today, and many more will gain coverage that could not afford it before,” Wright stated. “More people with health coverage not only helps individuals and families better plan for their financial future, but also helps stabilize the market, lowering costs for everyone.” The Affordable Care Act, a federal law enacted in 2010, allowed the states to create health insurance exchanges where residents could purchase individual health insurance plans and receive federal subsidies, if eligible. The law has been challenged in court and has been ruled unconstitutional by a federal court in Texas. “If the Affordable Care Act were repealed, what would it mean?” Lee said. “More than 20 million Americans would be at risk of losing their coverage. ...We would go back to the days of far more Californians without insurance. We'd go back to insurance companies being able to select who gets covered. We'd go back to the days of health benefit designs that meant consumers didn't know what they were getting when they signed up and might be at risk for not having coverage when they needed it.” Gov. Gavin Newsom, also spoke in favor of keeping the ACA, asserting that the Trump administration's efforts to eliminate the law will increase premiums if successful. If there is a smaller risk pool, insurers will increase rates. © 2020 Thomson Reuters. No claim to original U.S. Government Works. -14- “If we don't have a diverse risk pool, everybody's premiums go up,” Newsom stated. With Anthem Blue Cross's return to much of the California market, 99.6 percent of residents will have two insurers to choose from. Eighty-seven percent will have three choices. The California exchange estimates the number of state residents obtaining exchange insurance will increase by 229,000 people. [FN23] Currently, 2.2 million people access insurance through individual policies, 1.39 million of those people have exchange policies. Southwest Colorado Premiums to Decrease by Thirty Percent Health insurance premiums through the Colorado health insurance exchange in southwest Colorado could decrease by an average of 30%. The Colorado Division of Insurance indicated that insurance companies proposed decreased prices for health insurance premiums through the Connect for Health Colorado, the state's exchange. The decrease in prices is dependent on federal funding that has not yet been approved. Approximately 3,000 people in La Plata County purchased health insurance for 2019 via the exchange. An additional 800 people purchased plans in Montezuma County. The savings would be possible due to a new reinsurance program that Gov. Jared Polis's administration prioritized. The Colorado Legislature passed the measure recently. “Reducing health care costs for Colorado families has been a primary focus of my administration, and today we are seeing the first signs that our hard work is paying off,” Polis indicated. The program will help insurance companies cover the cost of insuring their most expensive customers. Claims of between $30,000 and $400,000 will qualify for the reinsurance, according to Joe Hanel, a spokesperson for Colorado Health Institute. The program lowers overall costs for health insurance companies, allowing them to pass on savings to consumers in the form of premium cost reductions. Southwest Colorado stands to see more of the savings than other parts of the state because reinsurance will cover a higher percentage of high-cost claims in those areas. Southwest Colorado residents currently face some of the highest premiums in the state for plans [FN24] available through the exchange. Colorado Receives Reinsurance Approval Colorado Gov. Jared Polis announced that the federal government approved the program for reinsurance that will help to lower the cost of health insurance premiums for consumers living in the state. The program could save some Colorado residents thousands of dollars on their health insurance premiums. Reinsurance allows the state to use federal funds to help insurers pay for their most expensive beneficiaries. The most expensive patients account for approximately fifty percent of health care spending nationwide. These patients, called super-users, make up about five percent of total patients. The high cost of their care increases costs for insurers and other consumers. Some states recently began reinsurance programs to help address the problem. It acts as insurance for health insurance companies to help them cover the high costs of super-users. Gov. Polis spoke in favor of the federal approval of the reinsurance program in Colorado. “The waiver for reinsurance has been granted!” Polis stated at a press conference to cheers from the crowd at the state Capitol. “Rates in Colorado will go down for the first time in history — 18.2 percent average statewide next year.” In areas with the highest cost for health insurance premiums, savings are expected to reach 33 percent. According to Adam Fox, director of strategic engagement with the Colorado Consumer Health Initiative, the reinsurance program will assist consumers who purchase plans through the individual market, especially those who do not qualify for federal tax subsidies. “This is great news for Coloradans,” Fox asserted. “It means that people can save money on their health insurance premiums and hopefully have a little more money to cover some of those out-of-pocket costs or put towards other needs in their daily lives.” On the Front Range, an average family of four could save over $3,300 per year on premiums. Savings could reach three times that amount for families living in western Colorado. Democratic state Sen. Kerry Donovan represents counties with some of the most expensive premiums in the United States. “Us being able to focus on saving them $9,000 a year if they're on the individual market, that's real money back into their family's budget,” she stated. Hospitals are not certain that the program will result in the expected savings, especially for people opting for high-deductible health plans. © 2020 Thomson Reuters. No claim to original U.S. Government Works. -15- “We are a little suspect of that,” noted Katherine Mulready, senior vice-president and chief strategy officer with the Colorado Hospital Association. “We want to make sure that total affordability, both premiums and out-of-pocket costs, the savings that we're talking about today of 18.2 percent, really get through to consumers.” According to Polis, deductible should stay stable. State insurance commissioner Michael Conway indicated that the program has received backing from both parties. “It's important to remember that this isn't just a blue state issue. We see red states doing it too,” Conway indicated. [FN25] State leaders predicted that savings will reach consumers as early as next year. North Dakota Reinsurance Program Approved North Dakota received federal approval of a program that will provide reinsurance for health insurance companies offering plans in the state. State Insurance Commissioner Jon Godfread announced that approximately 21,000 North Dakota residents will benefit from the program because of more affordable health insurance premiums. Godfread estimated that the reinsurance program could reduce rates for residents who purchase their insurance on the individual market by eight to twenty percent. He indicated that most people in the state purchasing individual health insurance plans are small business owners, farmers and ranchers. In recent years, their premiums have increased. “As rates have increased on the individual market, it's really pushed out those small business owners, farmers and ranchers, because they can't afford it,” Godfread stated. The reinsurance program will help insurance companies cover the costs of their most expensive claims. Consumers will see the benefit of the program when the insurance companies pass on the savings in the form of premium cost reductions. Under the North Dakota program, the state will pool federal and state money to pay for the high-cost patients. The Affordable Care Act permits states to apply for permission to use federal funds for reinsurance programs. North Dakota and Colorado received recent approval for reinsurance programs, bringing the number of states with the programs to ten. Godfread and members of the North Dakota legislature have opposed the Affordable Care Act, asserting that it increased costs. Godfread indicated that his department began a study about decreasing costs, which led to the drafting of the legislation to create a [FN26] reinsurance program using federal funding. CMS Creates New Star Ratings for Exchange Insurers The Centers for Medicare & Medicaid Services (CMS) announced that it will require ratings based on a five-star Quality Rating System nationwide for health insurance plans available through the Health Insurance Exchanges beginning with the 2020 open enrollment period. According to CMS, “This step builds on the Trump Administration's overall commitment to increasing transparency and empowering consumers to make informed healthcare decisions for themselves and their families.” The ratings will be available during this year's open enrollment period, allowing consumers to compare health insurance coverage based on a five-star quality rating of each plan on the websites for the exchange. HealthCare.gov, the federally run healthcare exchange website, and the state-run exchange websites will include the ratings. The star-rating system will be similar to other CMS star rating programs, including the Nursing Home Compare website and Medicare Advantage. “As part of the Trump Administration's broader quality initiative, I am pleased to announce that we are expanding display of star ratings to the Exchanges,” stated CMS Administrator Seema Verma. “Knowledge is power, and for the first time, consumers will have access to meaningful, simple-to-use information to compare the quality, along with the price, of health plans on Exchange websites, including HealthCare.gov. This addresses our strongly held commitment to equip consumers with the tools they need to find the best choice possible. Increasing transparency and competition drive better quality and cost, with consumers benefitting the most.” The new rating system will include ratings for all exchange health plans based on a 5-star system, with rankings from 1 to 5. The highest quality plans will be given a rating of five stars. The ratings will be based on several important factors, such as how enrollees rate the physicians included in the plan's network and how they rate the care they receive under the plan. Other factors include how well the plan's network providers coordinate with enrollees and other physicians to achieve the best results for patients. Also, the overall administration of the plan including customer service will be factors affecting ratings. Star ratings may not be immediately available for new plans, plans with low enrollment, or plans in all areas of the country. © 2020 Thomson Reuters. No claim to original U.S. Government Works. -16- The absence of a star rating will not mean that a plan is low quality. The star rating of a plan will depend on ratings in three categories, including Medical Care, Member Experience and Plan Administration. The category of Medical Care is based on how well the network providers included in the plan provide healthcare such as regular screenings, vaccines, and additional basic health services. The Member Experience category is based on a sample of member satisfaction levels with their healthcare and physicians, as well as the ease of obtaining appointments and medical services. The category of Plan Administration is based on the operation of the plan, including customer service, access to information, and the ordering of proper tests and treatments by providers. CMS tested the ratings system in two states, Virginia and Wisconsin, during the 2017 and 2018 open enrollment periods. CMS extended this pilot program to three additional states, Michigan, Montana, and New Hampshire, during the 2019 open enrollment period. The upcoming open enrollment period will include star ratings for plans in every state beginning this fall. CMS posted star ratings and quality measure level data from the 2019 Plan Year in a Public Use File. The public, researchers, agents, brokers, states, health issuers, and consumer groups will be able to use this information to analyze plan performance. According to CMS, “One of CMS's primary goals is to offer Americans who choose to enroll in the Exchanges the best consumer experience possible. Displaying health plan quality information makes it easier for consumers to pick a plan that best meets their needs. CMS is also further advancing its commitment to improve the accuracy and value of the information available to consumers and promoting quality improvement in the healthcare industry.” [FN27] The open enrollment period will begin on November 1, 2019 and end December 15, 2019. GA Farm Bureau Plans to Be Offered Outside of Exchange Georgia Gov. Brian Kemp announced that Georgia Farm Bureau and Anthem Blue Cross Blue Shield will offer health insurance plans outside of the state's health insurance exchange. Farm bureau members will be allowed to join a multiple employer welfare arrangement (MEWA). Under that arrangement, they will be able to purchase individual health insurance plans outside of the health insurance exchange. That will allow them to purchase health plans not offered to individuals on the Obamacare healthcare exchange. Anthem Blue Cross Blue Shield will underwrite the plans. The company indicated that the plans will be “similar to those available in the [FN28] ACA marketplace.” More States Return to State-Run Exchanges Seven years after the launch of health insurance exchanges created under the Affordable Care Act, only eleven states and Washington, D.C. run their own exchanges. Now, six states are returning to state-run exchanges or considering a return. Originally, Hawaii, Nevada and Oregon planned to create state-run exchanges but abandoned those plans when obstacles proved overwhelming. They chose the federal marketplace instead. California, Colorado, Massachusetts, Maryland and Washington experienced multiple issues with the technology of state-run exchanges and spent millions of dollars to fix the problems and save their state-run marketplaces. Maine, New Mexico, New Jersey, Nevada, Oregon and Pennsylvania are now considering creating state-run exchanges or are already on their way to doing so. State officials are confident they can prevent the past issues from resurfacing. They are relying on the successes of other state-run exchanges and the improved knowledge of their populations and geography as related to the health insurance market. The states are aimed at increasing enrollment and potentially reducing the cost of premiums with well-run state exchanges. According to industry experts, vendors have created software and technology for functioning state-run exchanges. “A lot of kinks have been worked out, and the ability to set up marketplaces that run effectively and efficiently has gone up,” indicated Jeanne Lambrew, commissioner of the Department of Health and Human Services in Maine. The state plans to switch to a state-run exchange in 2021. “We know much more now than states knew back in 2013,” stated Lambrew. Lambrew assisted Obama in implementing the ACA as deputy assistant for health policy. All states considering the switch to a state-run exchange have Democratic governors. All of them except for Pennsylvania have Democratic legislatures. © 2020 Thomson Reuters. No claim to original U.S. Government Works. -17- Some Republican governors are also considering a switch. Nevada's last governor, Republican Brian Sandoval, began a move to change to the state-run marketplace. The house majority leader in Pennsylvania, Republican Bryan Cutler, has been in favor of a change. The bill to create a state exchange in Pennsylvania passed both chambers unopposed. According to Cutler, a state-run exchange falls in line with Republican values. “Our philosophy is that local control is always best,” he asserted. “Time and again, it's proven that states can do it better and cheaper than the federal government.” He indicated that President Trump has not shown opposition to state-run exchanges and neither has the U.S. Department of Health and Human Services (HHS). The National Academy for State Health Policy (PDF) recently released a report showing that state-run exchanges had higher enrollment and cheaper premiums than the federal exchange. Enrollment in the federal exchange decreased by 3.7% this year while enrollment in state-run exchanges increased by less than 1%. Between 2016 and 2018, premiums increased by 71% for the federal exchange. They decreased by 40% for state-run exchanges. [FN29] Delaware Insurance Rates Expected to Decrease The cost of health insurance through Delaware's health insurance exchange is expected to decrease an average of 19 percent in 2020. State Insurance Commissioner Trinidad Navarro announced the expected decreases. The decrease, Navarro stated, “has never happened before in the history of the” Affordable Care Act. “It's going to lower rates probably near a negative 20 percent,” Navarro stated. The decrease in prices is the result of a reinsurance program that the federal government allowed the state to implement under a 1332 waiver. The reinsurance program will cover the cost of insurers' most expensive beneficiaries in the state with a pool of money. All insurance companies in the state will pay a 1 percent fee into the program. “For those folks who were paying more for their insurance than their mortgage, this is really going to help,” Navarro stated. Approximately 22,000 Delaware residents purchase health insurance plans through the state's exchange. Navarro indicated that the insurance marketplace in the state has stabilized in spite of “what I call efforts to kill the ACA through 1,000 papercuts.” Navarro pointed to the Trump administration's efforts to weaken the ACA by shortening the open enrollment periods, cutting funding for advertising and education, and other methods. He indicated that enrollment in Delaware has decreased. Navarro indicated that Delaware's small size makes change in the health insurance market difficult. Only one company, Highmark, [FN30] participates and the exchange and only three major hospitals serve the state. Colorado Rates to Decrease by Twenty Percent Colorado officials revealed that insurance premiums for 2020 are set to decrease by an average of twenty percent throughout the state. Some residents of rural areas of the state will see even higher reductions in the cost of their health insurance premiums. The decreases were not a surprise since preliminary rate inquiries in July indicated that premiums would cost an average of 18.2% less in 2020. Gov. Jared Polis and Colorado Insurance Commissioner Michael Conway spoke in favor of the significant decreases in the cost of premiums. They credited the state's new reinsurance program passed by the Colorado legislature earlier in the year and approved by the U.S. Department of Health and Human Services in July as a driving force behind the lower prices of premiums. According to Polis and Conway, decreases in prices across all plan tiers ranged from 15.5% to 34%. Customers in some rural areas of the state could see average decreases in premium prices over 30%. However, the number of counties served by only one health insurance company through the state's exchange, Connect for Health Colorado, will increase from 14 to 22 in 2020. Two companies, Kaiser and Friday Health Plans, will both exit some counties in Colorado. The companies had no customers in some of those counties. All current companies that offer plans through the exchange in Colorado will continue offering plans in at least one county in 2020. A new company, Oscar Health, will also offer plans to Colorado residents. State officials indicated that eight health insurance companies offer a total of 130 plans through the exchange. © 2020 Thomson Reuters. No claim to original U.S. Government Works. -18- “These decreases translate into real savings for Coloradans,” Conway noted. “These big premium decreases will give more people the opportunity to access health care for themselves and their families. For those with coverage today, these premium decreases will make life easier, which is why we come to work every day.” Rep. Julie McCluskie sponsored the legislation implementing the reinsurance plan. She called the price decrease “big news.” “Health insurance rates sold on the individual market will be falling dramatically, and the typical family of four living in the mountains and some rural areas of our state will see a savings of over $10,000 next year,” she indicated. “Every Coloradan deserves access to high- quality, affordable health care services close to home, and the General Assembly worked tirelessly this past year to deliver on this basic human right. From Colorado hospitals and insurance carriers, to the lawmakers who cosponsored this legislation, I am grateful for the collaborative efforts of all the partners and stakeholders who helped secure this reduction in health care costs.” “Plan prices and benefits change every year. We hear from customers that their medical needs, budgets and household situations also change,” asserted Connect for Health Colorado Chief Executive Officer Kevin Patterson. “That's why we're encouraging everyone to compare plans and think about the total costs of care before making a selection.” “This is especially good news for rural Coloradans who have been struggling with exceedingly high premiums,” stated Colorado Consumer Health Initiative Executive Director Adela Flores-Brennan. “Average premium decreases in the rural areas and mountains will range from 27.7-30 percent, meaning Coloradans in these areas will see a bit of much-needed relief.” Colorado Hospital Association President and CEO Steven Summer indicated that the association was in favor of the decreased prices for individual health insurance plans. “While other data sources may lag a few years, premiums are a leading indicator of where Colorado is on health care costs,” Summer [FN31] stated. “…The next step is to work on a more sustainable program targeting the total cost of care.” Report: States Considering State-Run Exchanges to Save Costs Georgetown University Health Policy Institute's Center on Health Insurance Reforms (CHIR) released a report showing that the states contemplating leaving the federal health insurance exchange to create their own state-run exchanges are motivated largely by potential cost savings. Only eleven states and the District of Columbia currently run their own health insurance exchanges. The remainder of states rely on the federal marketplace to serve as a health insurance exchange for consumers interested in purchasing private individual health insurance plans. Six states are considering plans to create their own health insurance exchange. Nevada will be the first to launch its plans with open enrollment starting Nov. 1. Maine, New Jersey and Pennsylvania plan on opening their exchanges for enrollment in 2021 plans. New Mexico is focused on a 2022 start date. Oregon is actively pursuing plans for a state-run exchange but has not chosen an implementation timeline. According to researcher Sabrina Corlette, co-director of CHIR, the states are motivated by cost (it's less expensive to create and run exchanges now than it was in the past) and by a desire for more market control. She pointed to Nevada's move to a state-run exchange, which has “sparked a real shift in thinking cost-benefit analysis coupled with some of the Trump administration policies that have been coming out that impact the ACA,” and has “states sort of seeking to have a little bit more control to ensure that those markets stay strong.” Insurers operating through Healthcare.gov must pay a user fee of 3.5% of premiums. Some states want those fees to go to state-run exchanges rather than to the federal government. Pennsylvania officials predict that the fees they recapture by switching to a state-run exchange can help to fund a reinsurance program. [FN32] GA Requests Waivers to Change Insurance Exchange Georgia Gov. Brian Kemp released waiver proposals aimed at completely changing the individual health insurance market in the state. The requested waivers are intended to help lower premiums and lessen federal control over health insurance exchanges. The federal government would have to approve the proposals for them to take effect. One of the proposals would allow the state to put aside over $300 million in federal money to help private insurance companies cover the cost of the most expensive claims, leading to lower overall premium prices. Another proposal that has received less support in Georgia would move control of the ACA exchange from the federal government to the state. Individual health insurance consumers in Georgia currently qualify for $2.7 billion in federal subsidies through the federal health insurance exchange. Those subsidies would become available through a state-run exchange if Georgia switched from the federal exchange. © 2020 Thomson Reuters. No claim to original U.S. Government Works. -19- “We live in a divided country and in a diverse state,” Kemp indicated. “But it's safe to say that Republicans, Democrats and independents agree on one thing: The insurance premiums are too dang high.” The proposal would create a website run by the state that would point Georgia residents to private web brokers and directly to insurance companies to choose individual health insurance plans. “No one has done this yet,” said Katie Keith, a professor of health law at Georgetown University. “This is exactly what the Trump administration encouraged states to do, and no one yet has taken them up on it. So this is going to be a really big deal.” Gov. Kemp and his advisors were confident that the proposals will receive approval from the White House. Democrats in the state opposed the legislation allowing Kemp to make the waiver proposals. They were critical of Kemp's plan to reduce state spending in the next two years by $500 million. Democrats were also critical of Kemp's opposition to Medicaid expansion, which he called too expensive. “While I'm glad that Governor Kemp is beginning to understand what Democrats have been saying for years, his plan doesn't go far enough,” indicated state Sen. Gloria Butler. “We need to get politics out of health care,” she stated. [FN33] Kemp will release another closely watched waiver proposal that could lead to a limited expansion of Medicaid. Silver Level Health Insurance Plans Cost Less, Unsubsidized Health Insurance Remains Unaffordable for Many The Centers for Medicare & Medicaid Services indicated that the average premium for a benchmark silver plan available through HealthCare.gov fell by 4% for 2020 coverage. However, many people still find the cost of unsubsidized individual health insurance plans too expensive. Twenty more health insurance companies will offer plans through the federal health insurance exchange beginning in 2020. In 2018, 132 insurers participated. In 2020, there will be 175. According to Health and Human Services Secretary Alex Azar, the cost of premiums for benchmark exchange plans decreased one percent from 2018 to 2019. “In total, 27 out of the 38 states on the federal exchange are seeing decreases in the benchmark premium. There will be 175 issuers offering plans on the federal exchange and an increase of 20 issuers from 2019,” indicated Azar. Two states will be served by a single health insurance plan available through the exchange in 2020. Last year, five states had only one plan. “The average enrollee will have 3.5 issuers available in 2020, compared with 2.8 issuers in 2019,” he stated. However, Azar also indicated that ACA plans are many times unaffordable if they are not federally subsidized. “For instance, a 27-year-old single person buying the second-lowest cost Silver plan in Nebraska is going to pay $583 a month for coverage, down from $687 in 2019,” he stated. “Now that's real savings. But she's still going to be spending almost $7,000 a year on insurance premiums when she could be making as little as $48,000 in income, and she will still have a sizable deductible to spend through.” In six states, the cost of benchmark plans will decrease significantly: Delaware (20%), Nebraska (15%), North Dakota (15%), Montana (14%), Oklahoma (14%), and Utah (10%). CMS Administrator Seema Verma pointed to the high cost of individual health plans without government subsidies. People who make too much to qualify for assistance “have been hit particularly hard and have found they simply cannot afford to keep their plan.” “Between 2016 and 2018 unsubsidized enrollment across the country declined by 2.5 million people, a 40% drop in just two years,” she [FN34] indicated. Idaho: Open Enrollment, Medicaid Automatic Enrollment In Idaho, open enrollment for plans available through the Affordable Care Act health insurance exchange began on November 1 and will continue to December 16. Idaho residents currently enrolled in exchange plans who will be eligible for Medicaid in 2020 will be automatically enrolled in the program. The state passed Medicaid expansion in November 2018. According to Your Health Idaho Executive Director Pat Kelly, approximately 18,000 current exchange customers in the state will qualify for coverage under Medicaid in 2020. Individuals and families earning up to 138 percent of the federal poverty level are eligible for Medicaid. People who are eligible for a federal tax subsidy to help pay for the cost of a private health insurance plan can find those plans through Idaho's health insurance exchange. © 2020 Thomson Reuters. No claim to original U.S. Government Works. -20- “We're really encouraging people to utilize our website, YourHealthIdaho.org, where they can go out and see what plan they're currently enrolled in, what plan they've been automatically renewed in (and) make sure that plan still works for them. It's a great service for them to see and shop,” indicated Kelly. In 2019, 85 percent of Idaho residents who purchased health insurance plans through the exchange were eligible for a federal tax subsidy. The average eligible Idaho resident received a tax credit covering 80 percent of the cost of the insurance plan. After the state expanded eligibility for Medicaid, state officials moved to automatically enroll eligible people who had private health plans through the exchange. “When we went through that renewal process, we said these people may become eligible for Medicaid, and they'll be automatically enrolled Jan. 1, 2020, in Medicaid. They also will not be renewed for their health insurance through Your Health Idaho,” Kelly stated. Kelly also pointed to the resources available to educate Idaho residents about eligibility for Medicaid and information about available health insurance plans. “Working with an agent or broker is really important for that. Those are the people in Idaho that have expertise. They're certified by Your Health Idaho, and they're licensed by the state. We have about 800 around the state. They can really help that family that says, ‘I'm not sure what I qualify for. I don't know how to go about a tax credit. And I'm not sure what plan works best for me,”’ Kelly indicated. The Idaho health insurance exchange website allows residents to enter their zip code to find nearby agents. The agents can help find health insurance plans for consumers. Consumers are not charged for the agents' services. Kelly urged Idaho residents to quickly take advantage of the open enrollment period. “Don't wait. That deadline of Dec. 16 feels like it's [FN35] a long way off. It's not.” Health Insurance Enrollment Down in Beginning Weeks of Open Enrollment The Centers for Medicare & Medicaid Services released enrollment numbers for the first weeks of open enrollment for health insurance plans available through the federal health insurance exchange for 2020, showing that enrollment was less than it was during the same period last year. Data showed that 932,049 people selected plans via the exchange from November 1 through November 9. Most of those people selected plans during week two of open enrollment, with 754,967 people selecting plans. People from 38 states have access to health insurance through HealthCare.gov, the federal platform for the health insurance exchange. CMS will release enrollment data every week during the open enrollment period. The data includes weekly plan selections, call center activity, and visits to the federal health insurance exchange website. The final enrollment numbers for those weeks will be subject to plan modifications and cancellations. The data only includes plan selections and plan renewals and does not report the number of consumers who have paid premiums to complete their enrollment in chosen plans. The states using the HealthCare.gov platform for the individual market Exchange include Alabama, Alaska, Arizona, Arkansas, Delaware, Florida, Georgia, Hawaii, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Michigan, Mississippi, Missouri, Montana, Nebraska, New Hampshire, New Jersey, New Mexico, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, West Virginia, Wisconsin, and Wyoming. Enrollment is down by 12% on an average daily basis from the same period during last year's open enrollment period. The average cost of premiums for a benchmark plan is 4% less than it was last year. Twenty more insurers will offer plans through the federal health insurance exchange than last year. Health care industry experts are blaming the Trump administration's efforts to eliminate the Affordable Care Act in court and the [FN36] decrease of funding for advertising and enrollment assistance for the fall in enrollment. © Copyright Thomson/West - NETSCAN's Health Policy Tracking Service [FN1] . Kodjak, Alison, “Affordable Care Act Insurance Sign-Ups Fall Slightly For 2019,” Shots Health News from NPR, December 14, 2018, available at https://www.npr.org/sections/health-shots/2018/12/14/676526601/aca-sign-ups-have-lagged-for-2019-but-what-does-that- mean. [FN2] . Johnson, Shauna, “Health insurance exchange enrollments continue to decline in West Virginia,” MetroNews, January 11, 2019, available at http://wvmetronews.com/2019/01/11/health-insurance-exchange-enrollments-continue-to-decline-in-west-virginia/. © 2020 Thomson Reuters. No claim to original U.S. Government Works. -21- [FN3] . Livingston, Shelby, “CMS wants to cut ACA exchange fees, end silver-loading,” Modern Healthcare, January 17, 2019, available at https://www.modernhealthcare.com/article/20190117/NEWS/190119916. [FN4] . Johnson, Shauna, “Health insurance exchange enrollments continue to decline in West Virginia,” MetroNews the Voice of West Virginia, January 2019, available at http://wvmetronews.com/2019/01/11/health-insurance-exchange-enrollments-continue-to-decline-in- west-virginia/. [FN5] . Brown, Nathan, “Exchange enrollment expected to drop 20% due to Medicaid expansion,” Idaho State Journal, January 24, 2019, available at https://www.idahostatejournal.com/news/local/exchange-enrollment-expected-to-drop-due-to-medicaid-expansion/ article_ac83a274-98b2-5998-a31b-46df00be461c.html. [FN6] . Miller, Andy, Georgia Health News, “Anthem, Amid Dispute With WellStar, Gives Exchange Patients A (Temporary) Break,” WABE.org, February 5, 2019, available at https://www.wabe.org/anthem-amid-dispute-with-wellstar-gives-exchange-patients-a- temporary-break/. [FN7] . Mary Shinn, “Bill aims to lower state health exchange costs by 30 percent,” The Pine River Times, February 19, 2019, available at https://pinerivertimes.com/articles/91696-bill-aims-to-lower-state-health-exchange-costs-by-30-percent. [FN8] . Michels, Holly K., “Lawmaker wants state tax breaks for people who buy health insurance on the individual market,” Independent Record, February 19, 2019, available at https://helenair.com/news/state-and-regional/govt-and-politics/lawmaker-wants-state-tax- breaks-for-people-who-buy-health/article_8bfbfe3e-759f-53c9-bde8-76abff38f510.html. [FN9] . Masterson, Les, “Rural areas hit hardest on unsubsidized ACA plans,” Healthcare Dive, March 6, 2019, available at https:// www.healthcaredive.com/news/rural-areas-hit-hardest-on-unsubsidized-aca-plans/549792/. [FN10] . Case Western Reserve University, “Health insurance is not assurance of healthcare,” EurekAlert!, February 27, 2019, available at https://eurekalert.org/pub_releases/2019-02/cwru-hii022719.php. [FN11] . “Governor Murphy Announces New Jersey to Transition to State-Based Exchange,” State of New Jersey Governor Phil Murphy, March 22, 2019, available at https://nj.gov/governor/news/news/562019/approved/20190322a.shtml. [FN12] . Faher, Mike, “House authorizes demise of association health insurance,” Vermont Digger, March 28, 2019, available at https:// vtdigger.org/2019/03/28/house-authorizes-demise-association-health-insurance/. [FN13] . Anderson, James, “Colorado Senate advances public health insurance bill,” The Aspen Times, April 16, 2019, available at https:// www.aspentimes.com/news/colorado-senate-advances-public-health-insurance-bill/. [FN14] . Livingston, Shelby, “CMS to allow copay accumulators, cut exchange user fees,” Modern Healthcare, April 18, 2019, available at https://www.modernhealthcare.com/insurance/cms-allow-copay-accumulators-cut-exchange-user-fees. [FN15] . Hawryluk, Markian, “Report raises concerns about Oregon's health insurance exchange,” The Bulletin, April 23, 2019, available at https://www.bendbulletin.com/localstate/7107483-151/report-raises-concerns-about-oregons-health-insurance-exchange. [FN16] © 2020 Thomson Reuters. No claim to original U.S. Government Works. -22- . Press release, “Historic ‘public option’ healthcare bill passes Legislature, heads to Inslee's desk,” Washington State House Democrats, April 28, 2019, available at https://housedemocrats.wa.gov/blog/2019/04/28/historic-public-option-healthcare-bill-passes- legislature-heads-to-inslees-desk/. [FN17] . Jenkins, Austin, “Washington becomes first state to offer public health insurance option, long-term care benefit,” KUOW, May 13, 2019, available at https://www.kuow.org/stories/washington-becomes-first-state-to-offer-public-health-insurance-option-long-term-care- benefit. [FN18] . Cohn, Meredith, “Obamacare consumers in Maryland could see insurance premiums drop next year,” The Baltimore Sun, May 10, 2019, available at https://www.baltimoresun.com/health/bs-hs-obamacare-rate-requests-down-20190510-story.html. [FN19] . Carleso, Jenna, and Keith M. Phaneuf, “Democrats unveil sweeping overhaul of public option bill,” The CT Mirror, May 23, 2019, available at https://ctmirror.org/2019/05/23/democrats-unveil-sweeping-overhaul-of-public-option-bill/. [FN20] . Ashby, Charles, “Guv signs health care bills,” The Daily Sentinel, May 18, 2019, available at https://www.gjsentinel.com/news/ western_colorado/guv-signs-health-care-bills/article_626f82c2-792f-11e9-8107-20677ce85d90.html. [FN21] . Levy, Marc, “Pennsylvania's own insurance exchange coming next year,” API, July 2, 2019, available at https:// www.apnews.com/745341c7e6a24750bccc50e23843b1da. [FN22] . Press release, “U.S. Departments of Health and Human Services, Labor, and the Treasury Expand Access to Quality, Affordable Health Coverage Through Health Reimbursement Arrangements,” HHS.gov, June 13, 2019, available at https://www.hhs.gov/about/ news/2019/06/13/hhs-labor-treasury-expand-access-quality-affordable-health-coverage.html. [FN23] . Anderson, Cathie, “Covered California says consumers will see lowest-ever premium hike for individual policies,” The Sacramento Bee, July 9, 2019, available at https://www.sacbee.com/news/local/health-and-medicine/article232432922.html. [FN24] . Shinn, Mary, “Insurance premiums may fall 30% for state health exchange customers,” The Journal, July 16, 2019, available at https:// the-journal.com/articles/145739. [FN25] . Daley, John, “Polis Celebrates Colorado's New Reinsurance Program, Which Could Lower Premiums In The Future,” CPR News, July 31, 2019, available at https://www.cpr.org/2019/07/31/polis-celebrates-colorados-new-reinsurance-program-which-could-lower- premiums-in-the-future/. [FN26] . Emerson, Blair, “North Dakota program aimed at reducing cost of health insurance gets federal approval,” Bismark Tribune, August 1, 2019, available at https://bismarcktribune.com/news/local/govt-and-politics/north-dakota-program-aimed-at-reducing-cost-of-health- insurance/article_0cea1262-1a7e-5846-9668-d451f83a968f.html. [FN27] . Press release, “CMS is Bringing Health Plan Quality Ratings to All Exchanges for the First Time,” CMS Newsroom, August 15, 2019, available at https://www.cms.gov/newsroom/press-releases/cms-bringing-health-plan-quality-ratings-all-exchanges-first-time. [FN28] . Whitehead, Sam, “Kemp Backs New Insurance Option Aimed At Rural Georgia,” WABE, August 29, 2019, available at https:// www.wabe.org/kemp-backs-new-insurance-option-aimed-at-rural-georgia/. [FN29] © 2020 Thomson Reuters. No claim to original U.S. Government Works. -23- . Ollove, Michael, Stateline, “States flubbed the rollout of their health insurance exchanges. Now, they're ready to try again,” Fierce Healthcare, September 16, 2019, available at https://www.fiercehealthcare.com/payer/states-flubbed-rollout-their-health-insurance- exchanges-now-they-re-ready-to-try-again. [FN30] . Magill, Kerin, “Delaware ACA insurance rates expected to tumble,” Coastal Point, October 3, 2019, available at http:// www.coastalpoint.com/46855/feature/delaware-aca-insurance-rates-expected-tumble. [FN31] . Miller, Blair, “Colorado announces 20% average reduction across individual health insurance premiums for 2020,” The Denver Channel, October 11, 2019, available at https://www.thedenverchannel.com/news/local-news/colorado-announces-20-average- reduction-across-individual-health-insurance-premiums-for-2020. [FN32] . Minemyer, Paige, “Handful of states mull getting off HealthCare.gov for their own exchanges,” Fierce Healthcare, October 10, 2019, available at https://www.fiercehealthcare.com/payer/why-states-are-mulling-launch-their-own-insurance-exchanges. [FN33] . Hart, Ariel, and Greg Bluestein, “Kemp unveils proposals to overhaul Georgia individual health plans,” AJC, November 1, 2019, available at https://www.ajc.com/news/state--regional-govt--politics/kemp-unveils-proposals-overhaul-georgia-individual-health-plans/ goksGHgRkJzvYBXQGIE8sJ/. [FN34] . Commins, John, “HEALTHCARE.GOV PREMIUMS FOR ‘BENCHMARK’ SILVER PLAN TO FALL 4% IN 2020,” Health Leaders Media, October 22, 2019, available at https://www.healthleadersmedia.com/finance/healthcaregov-premiums-benchmark-silver-plan- fall-4-2020. [FN35] . Price, Mike, “Open enrollment is here — more Idahoans will now automatically qualify for Medicaid,” EastIdahoNews.com, November 14, 2019, available at https://www.eastidahonews.com/2019/11/open-enrollment-is-here-more-idahoans-will-now-automatically-qualify- for-medicaid/. [FN36] . CMS, “Federal Health Insurance Exchange Weekly Enrollment Snapshot: Week 2,” CMS Newsroom, November 13, 2019, available at https://www.cms.gov/newsroom/fact-sheets/federal-health-insurance-exchange-weekly-enrollment-snapshot-week-2; Luhby, Tami, “Sign-ups slip in initial days of Obamacare open enrollment,” CNN Politics, November 13, 2019, available at https:// www.cnn.com/2019/11/13/politics/obamacare-open-enrollment/index.html. Produced by Thomson Reuters Accelus Regulatory Intelligence 04-Feb-2020 © 2020 Thomson Reuters. No claim to original U.S. Government Works. -24-