Passage of the Republican-sponsored tax reform bill last December enables individuals to forego purchasing health insurance without paying a fine; effectively reversing the American Care Act (ACA) requirement.
Meanwhile, the Department of Labor, consequent to a Trump executive order, has expanded the capacity for small-business membership in Association Health Plans (AHPs), while constricting the AHP regulatory authority of states by shifting this to the federal government.
AHPs may pose a unique threat to healthcare providers, in that fraud has historically permeated AHP handling of medical claims. The persistent deregulation efforts of the Trump Administration have widespread ramifications for healthcare provisions across the United States, regardless of whether the ACA remains federal law under his tenure.
The Affordable Care Act benefit and payment parameters are out the window.
The new rule for Affordable Care Act Benefit and Payment Parameters for 2019 went into effect June 18. This Department of Health and Social Security (DHSS) rule grants states an expanded role in what they can choose as an Essential Benefits Benchmark Plan. The near term impact is that it can aid insurers in limiting the actual essential health benefits (EHBs) offered within any specific EHB category.
On the other hand, this can also leave insured people who need preventive care (or services within a different EHB category, such as mental health care) with fewer options. One of the two Trump Administration guidance documents included in this rule expands the hardship exemption, so more individuals can be exempt from purchasing state-required health insurance coverage.
Also eliminated by this rule is the requirement for insurance marketplaces to have at least two Navigator entities to assist consumers in selecting appropriate insurance coverage. The SHVS perceives that this final rule reflects anti-ACA policy designed to expand the role of states in providing oversight and administering the ACA while simultaneously reducing federal ACA oversight.
Caps on insurance premium increases are being loosened.
The Centers for Medicare and Medicaid Services (CMS) rule pertaining to the Medical Loss Ratio (MLR) under state regulatory authority has also been changed from the previous version.
The ACA mandated that premium rate increases of 10 percent or more in the individual market needed to be scrutinized by state regulators in order to determine the increases were reasonable. The new CMS rule raises that threshold to 15 percent. While insurance companies have reacted favorably, the resulting cost increase in healthcare services is likely to be passed on to healthcare facilities, medical providers, and patients.
Medicare penalties enacted against negligent nursing homes have been eliminated.
Under the leadership of Trump appointee Seema Verma, the CMS has instituted new rules curbing the oversight of nursing homes. The New York Times reported last November that the CMS was scaling back the use of fines against nursing homes that place residents at risk of injury.
In a CMS memo from last July, directors of state agencies that survey nursing homes for safety were discouraged from issuing daily fines for violations in favor of one-time fines, thereby sheltering nursing homes from the impact of receiving such fines.
CMS also proposed reversing an Obama-era rule prohibiting clauses in nursing home residents’ contracts that require residents to use arbitration to settle disputes rather than seek redress in a court of law. As a concession to nursing home resident advocacy groups, the CMS-proposed rule requires the arbitration agreement be written in “plain language.” Yet even the nursing home industry responded that “plain language” is too vague for any actual enforcement.
In the case of a hospitalized elderly person physically unable to return home, family members are likely to sign arbitration agreements just to ensure a residential placement for that individual, regardless of whether they understood the terms.
Trump-era policies and safety-net program work rules set tough standards on the poor.
Kentucky, Indiana and Arkansas became the first states to impose the Trump Administration’s Jan. 11 guidance enabling states to impose work requirements on Medicaid recipients. The following seven other states also applied for DHSS permission to impose work requirements on their Medicaid enrollees immediately after issuance of the Trump guidance document: Arizona, Kansas, Maine, New Hampshire, North Carolina, Utah and Wisconsin.
In May, New Hampshire became the latest state to impose a Medicaid work requirement. That state’s CMS waiver also imposes premium co-pays for recipients with incomes exceeding 100 percent of the Federal Poverty Level (FPL). The National Academy for State Health Policy reports that 30 states have now proposed (or are in the process of) implementing Medicaid work requirements.
In April, Trump additionally signed an executive order called “Reducing Poverty in America” that requires low-income recipients of food assistance (e.g., SNAP benefits), low-income housing subsidies and Medicaid to work or lose eligibility status.
Trump’s plan for cost-containment of prescription medications has faltered.
Although originally promised, President Trump decided against the federal government directly negotiating for lower drug prices for Medicare Part D recipients, as well as allowing US consumers to import medications from abroad.
In a recent speech (May 2018), timed to broaden appeal for his base ahead of the November congressional elections, Trump promised instead to provide private entities with more tools to negotiate better price deals. Stock shares of pharmaceutical and biotech companies—as well as Pharmacy Benefit Managers (PBMs)—immediately rose.
A newsletter aimed at pharmaceutical and biotechnology industry members noted Trump’s proposed trade tariff aimed at China could actually increase the cost of medications in the US, since the FDA reported that 80 percent of active pharmaceutical ingredients used by US manufacturers are imported from China.
There are serious safety implications to regulatory rollbacks at the FDA.
One of President Trump’s stated goals is a 75-percent roll back of FDA regulations. FDA Commissioner Scott Gottlieb was credited by the pharmaceutical industry and healthcare organizations with streamlining the FDA drug approval process. Indeed, the FDA in 2017 set an all-time record for generic drug approvals and novel drugs compared to any year after 1996.
Gottlieb recently suggested that the legal status of rebates paid to insurers and Pharmacy Benefit Managers (PBMs) may be rescinded as a way to potentially reign in drug costs through increasing competition.
Meanwhile ‘Right to Try’ legislation in May was signed into federal law by President Trump. This law allows terminally ill people the right to take experimental medications not yet approved by the FDA.
The jury is still out as to whether speeding up the availability of new medications was a safe policy or not, and whether reducing rebates will help control prescription drug costs in the future.
The medical community has a responsibility to advocate for preserving and protecting the US healthcare system.
Donald Trump has been in office for less than two years, but has already shown a striking disregard for ensuring that all Americans—particularly the most vulnerable among us—can access healthcare services. For Medicaid recipients, imposing a work requirement can mean choosing between going without health insurance or leaving a disabled child alone at home for hours, if the parent’s work hours do not match that of the child’s school or care program.
Likewise, family caregivers seeking a nursing-home placement for elderly family members may face far greater risks of neglect or mistreatment by the nursing home due to a weakening of regulations for those entities and care requirements. That’s enough to make folks reluctant to move a loved one away family provided care.
The consequence of limiting access to preventive care is already well known to medical providers and other clinicians. The Congressional Budget Office calculated that the repeal of the ACA’s individual mandate by itself would increase the number of uninsured Americans to four million in 2019. Taken as a whole, the changes under the Trump Administration to Medicare, Medicaid and the private insurance industry will increase difficulties for patients in accessing healthcare. In turn, physicians, hospitals, and the entire healthcare delivery system will absorb the cost-burden created by the Trump Administration’s healthcare policies.
The time to act is now: Before healthcare facilities become overburdened with patients unable to pay their medical bills; or those with preventable illnesses that were left untreated are in critical condition.
Overturning the ACA is a major goal of President Trump, so demonstrating it as a failure is a specific strategy he uses to garner public support for its repeal. But attempting to generate failure in the healthcare system does not bode well for healthcare providers or patients.
It is imperative that we learn from the lessons of the past.
The last attempt at massive healthcare deregulation was under President Ronald Reagan. The adverse consequences from that effort included attempts at cost-control backfiring, and healthcare outcomes worsening.
We need advocacy work from healthcare providers, insurers and patients in order to ensure that the quality of our healthcare system is not exchanged for short-term political achievements that foster a weakened governmental capacity to produce a healthier nation in the coming decades.
