National

From our Expert Voices conversation on plans for health care reform after Trump's executive order:

The executive order calls for broadening the definition of a "bona fide group or association" to allow a greater number of small employers that are members of local chambers of commerce or a national trade association to form fully insured "large group" or self-insured "group" association health plans.

While it's true that association health plans would not be subject to the ACA's "essential health benefits" and "actuarial value" requirements — rules that apply to "small group" and "individual" market plans — this exemption has been misrepresented to suggest that these plans can (1) deny a person coverage if they have a pre-existing condition, (2) refuse to cover preventive services, and (3) impose annual and lifetime limits on the essential health benefits.

All three claims are false. Those practices are prohibited under ACA "group health plan" standards that continue to apply. And others remain in force too — most notably, coverage for adult children up to age 26, free access to emergency care, and protections against rescinded coverage except in cases of fraud.

A fully insured association health plan is also subject to state benefit mandates, most of which are as good if not better than the federal "essential health benefit" standard. Penalties may apply to self-insured association health plans that do not cover specific "essential health benefits," including hospitalization and physician services.

Why it matters: Association health plans are by definition required to provide adequate coverage, and additional federal protections apply, including fiduciary responsibilities, a rigorous appeals process, and prohibitions against basing premium rates on an individual participant's health condition.

James Capretta, resident fellow at the American Enterprise Institute and former associate director for health programs at the OMB: Alexander-Murray deal a flawed first attempt at bipartisanship

John McDonough, professor at the Harvard T.H. Chan School of Public Health and former Senate adviser on health reform: Obamacare is dead. Long live the Affordable Care Act.

Jeanne Lambrew, senior fellow at the Century Foundation and deputy assistant to the president for health policy in the Obama White House: Health care fix today could be undone tomorrow

Tevi Troy, CEO of the American Health Policy Institute and former deputy secretary of HHS: Expanding HRAs would bolster individual market

Clearing the air on AHPs

Expert Voices

From our Expert Voices conversation on plans for health care reform after Trump&#x27;s executive order:The executive order calls for broadening the definition of a &quot;bona fide group or association&quot; to allow a greater number of small employers that are members of local chambers of commerce or a national trade association to form fully insured &quot;large group&quot; or self-insured &quot;group&quot; association health plans.While it&#x27;s true that association health plans would not be subject to the ACA&#x27;s &quot;essential health benefits&quot; and &quot;actuarial value&quot; requirements — rules that apply to &quot;small group&quot; and &quot;individual&quot; market plans — this exemption has been misrepresented to suggest that these plans can (1) deny a person coverage if they have a pre-existing condition, (2) refuse to cover preventive services, and (3) impose annual and lifetime limits on the essential health benefits.All three claims are false. Those practices are prohibited under ACA &quot;group health plan&quot; standards that continue to apply. And others remain in force too — most notably, coverage for adult children up to age 26, free access to emergency care, and protections against rescinded coverage except in cases of fraud.A fully insured association health plan is also subject to state benefit mandates, most of which are as good if not better than the federal &quot;essential health benefit&quot; standard. Penalties may apply to self-insured association health plans that do not cover specific &quot;essential health benefits,&quot; including hospitalization and physician services.Why it matters: Association health plans are by definition required to provide adequate coverage, and additional federal protections apply, including fiduciary responsibilities, a rigorous appeals process, and prohibitions against basing premium rates on an individual participant&#x27;s health condition.Other voices in the conversation:<ul><li>James Capretta, resident fellow at the American Enterprise Institute and former associate director for health programs at the OMB: Alexander-Murray deal a flawed first attempt at bipartisanship</li></ul><ul><li>John McDonough, professor at the Harvard T.H. Chan School of Public Health and former Senate adviser on health reform: Obamacare is dead. Long live the Affordable Care Act.</li><li>Jeanne Lambrew, senior fellow at the Century Foundation and deputy assistant to the president for health policy in the Obama White House: Health care fix today could be undone tomorrow</li><li>Tevi Troy, CEO of the American Health Policy Institute and former deputy secretary of HHS: Expanding HRAs would bolster individual market</li></ul>

Every news article I read about the House GOP health care compromise suggests that it would allow states to waive the Affordable Care Act's pre-existing condition protections. That is not what the amendment would do. Nor would it allow insurance companies to charge higher premiums for people with a health condition in all cases.

All the amendment would do is to allow insurance companies to charge higher premiums for individual market customers with a health condition, but only in cases where they did not maintain "continuous coverage." And it's critical to understand the difference.

The back story: Under the ACA, insurance companies are prohibited from developing premium rates based on an individual's health condition. Premium rates can only vary by age, by tobacco use, by geography, and by family size. These rules apply to individual market plans and "group" plans offered by small employers.

What the amendment really does: Previous discussions of a possible compromise between Reps. Tom MacArthur, a leader of the moderate Tuesday Group, and Freedom Caucus Chairman Mark Meadows suggested that states would be able to let insurers charge higher premiums for all individual market plan holders with a health condition.

But the actual amendment doesn't do that. Instead, the amendment would give states the option to allow the insurance companies to charge higher premiums for a person with a health condition only if they (1) lose their health coverage and (2) fail to obtain new health coverage within 63 days.

This means that the protections against being charged higher premiums for a health condition are preserved for every individual market plan holder who maintains continuous coverage. These protections would also be in place for new enrollees (so long as they maintain continuous coverage going forward).

The safety net: Some have argued that if insurance companies can charge higher premiums for a health condition, vulnerable people would be "priced out of the market" by making their health coverage unaffordable. I agree with this argument. And, it appears that MacArthur and Meadows agree as well.

Which is why the MacArthur-Meadows amendment says a state can only let insurers charge higher premiums if it establishes a "high-risk pool" or participates in an "invisible high-risk pool" program (which compensates insurers for covering expensive patients and would be funded at $15 billion).

Why is this significant? Because for those people with health conditions — who do not maintain continuous coverage, and who are therefore charged higher premium rates — they will always have "access" to health coverage, even if they are "priced out of the market."

I recognize that high-risk pools have been problematic in the past. Historically, high-risk pools have had funding deficiencies. In addition, the coverage offered through a high-risk pool has sometimes been inadequate.

And therefore, it is reasonable to oppose this new compromise amendment because — based on past precedent — high-risk pools haven't worked. (Although the GOP bill does provide $100 billion for the Patient and State Stability Fund, to set up high-risk pools, and an additional $15 billion for maternity care/newborn coverage and mental health/substance use disorders).

But to claim that the MacArthur-Meadows amendment takes away protections for people with pre-existing conditions — and fails to protect people with a health condition — is incorrect.

What the new House GOP plan really does on pre-existing conditions

It's only focused on people with health conditions who don't keep themselves insured.

Health Care

Politics

Every news article I read about the House GOP health care compromise suggests that it would allow states to waive the Affordable Care Act&#x27;s pre-existing condition protections. That is not what the amendment would do. Nor would it allow insurance companies to charge higher premiums for people with a health condition in all cases.All the amendment would do is to allow insurance companies to charge higher premiums for individual market customers with a health condition, but only in cases where they did not maintain &quot;continuous coverage.&quot; And it&#x27;s critical to understand the difference.

Christopher Condeluci (health care policy lawyer)

Stories

Clearing the air on AHPs

What the new House GOP plan really does on pre-existing conditions