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The Most Important Health Officials You’ve Never Heard Of: Insurance Commissioners In Hot Seat

Kaiser Health News:HealthReform - September 06, 2017

With insurance premiums rising and national efforts at health reform in turmoil, a group of 50 state bureaucrats whom many voters probably can’t name have considerable power over consumers’ health plans: state insurance commissioners.

As insurers threaten to exit state markets and voters at town halls complain about unaffordable prices, the state commissioners are central characters in the unfolding drama that is America’s health coverage.

“What’s the worst job to have right now? Insurance commissioner,” said Christopher Koller, a former commissioner from Rhode Island who is president of the Milbank Memorial Fund, a foundation that works to improve health. “They’re trying to keep the market stable.”

This KHN story also ran in The Washington Post. It can be republished for free (details).

Most are wrestling with how to take on this task amid ongoing political rancor over the fate of the Affordable Care Act. Several commissioners are slated to testify Wednesday before the Senate health committee to talk about market stability and how to ensure patients have affordable health care.

The political debate highlights the role of this crew of wonk-ish administrators who sometimes preside over underfunded, understaffed offices and whose range of duties usually spans well beyond health care and its myriad complexities.

In all but one state, the commissioner regulates all types of insurance, and in several he or she might hold other jobs — such as lieutenant governor (Ohio), state auditor (Montana) and fire marshal (Mississippi, North Carolina, Tennessee and Georgia).

Most commissioners have the authority to reject premiums or modify rates they deem excessive. They also have the power of their bully pulpit. Though California Commissioner Dave Jones, for example, lacks the statutory muscle to override insurers’ rate increases, he often uses his position to publicly call out insurers’ premium hikes.

But critics worry that in some states the position is a revolving door with industry, moving them to do less than they could.

“It a double-edged sword,” said Sabrina Corlette, research professor at Georgetown University’s Health Policy Institute. “Knowledge of industry … is very important in the job. [But] … if someone is coming from and going back to industry, it does raise some red flags about where their interests really lie.”

Sometimes a past résumé draws increased public scrutiny of a regulator’s actions on issues under the department’s purview.

Connecticut Insurance Commissioner Katharine Wade, who was a Cigna executive before being named commissioner, was fined $500 in June after the state’s Freedom of Information Commission ruled that she improperly withheld documents related to a proposed merger between Aetna and Humana. She is currently appealing the ruling. The proposed merger was called off in February after a federal court blocked the deal, but not before a state review of Connecticut-based Aetna’s plan drew criticism because of Wade’s past employment.

Eleven commissioners are elected and the remainder are appointed and — as such — face new political pressures in a highly partisan health care debate.

When Julie Mix McPeak, commissioner of Tennessee’s Department of Commerce and Insurance, persuaded Blue Shield to return to areas of the state that it had pulled out of last year, she recalled: “Some critics said I was going out of my way to prop up Obamacare. Others said I wasn’t doing enough because I’m from a red state and that must mean we want Obamacare to fail. But I just want access to coverage.”

Historically, insurance commissioners have stayed out of political battles, said Tim Jost, emeritus professor at the Washington and Lee University School of Law who also serves as a consumer advocate with the National Association of Insurance Commissioners (NAIC). They see “themselves as civil servants more than politicians,” he said.

But, he added, “at least for the moment, it’s more politicized than it has been in the past.”

The individual insurance market, where about 17 million people purchase their own plans because they don’t get it through their jobs, is the focus for much of this drama.

GOP repeal-and-replace talking points have hammered a message that the individual market — including these government exchanges — are imploding. But Democrats counter that though they face difficulties, this is not the case. The insurance commissioners are caught in the middle and have the power to make either narrative come true.

Many had to scramble this summer — negotiating, offering incentives or just downright pleading — to get insurers to stay in their markets.

At one point, there were more than 40 counties nationwide with zero insurers for next year. As of Aug. 24, when insurer CareSource agreed to provide coverage in Ohio’s Paulding County, no more of these so-called “bare counties” remained.

McPeak and other commissioners also say that cost issues need to be tackled, but there’s no bandwidth to take on these thorny issues because they have to deal with the more immediate problems.

“We can’t get to affordability if I don’t have a policy for people to buy,” said McPeak. For next year, “I’m telling consumers there will be problems and they will see rate increases. But at least they have an option.”

These efforts are made more complicated by President Donald Trump’s repeated threats to eliminate subsidies used to lower deductibles for some ACA policyholders, which would raise premiums. Payments are currently being made on a month-to-month basis. It will likely be a topic during the upcoming Senate hearing.

“We would all like to know what the rules are. When there is uncertainty, it’s difficult to make short- or long-term decisions, said Al Redmer, who was appointed Maryland’s insurance commissioner in 2015 by Republican Gov. Larry Hogan.

And the subsidies aren’t the only point of contention, with the partisan divide also reflected among some commissioners.

Trump and Congress are causing uncertainty that is “sabotaging the progress we’ve made,” Washington state Insurance Commissioner Mike Kreidler wrote in June. His state strongly embraced the ACA.

Kreidler, a Democrat who formerly was a member of Congress, was first elected commissioner in 2000.

In contrast, Oklahoma Insurance Commissioner John Doak, whose state opposed the ACA from the start, has made it no secret that he supports repeal of the law, calling it “this disastrous experiment.” Doak, a Republican who was elected to the position in 2010 after working for various insurance companies, blamed ACA regulations for “so many insurers dropping out of exchanges or resorting to double digit premium increases.”

Commissioners’ regulatory powers vary by state, depending on the rules state legislators have put in place for them to enforce.

“Some states have comprehensive protections for consumers … while others have limited protection,” said Claire McAndrew, director of campaign strategy at Families USA.

But if they are so motivated, consumers can always find means to take an activist role.

Past commissioners, for instance, talk of using the regulatory process itself — pushing the boundaries in drafting the rules or using a “slow walk” toward their implementation — to work around these boundaries.

Even so, they face other limits. For instance, staffing levels for their departments are down nearly 6 percent since 2008, according to the most recent NAIC statistics.

That’s a big disadvantage when contrasted with the “strength of insurance industry lobby,” said J. Robert Hunter, a former Texas commissioner and now director of insurance at the Consumer Federation of America.

And some fail to counter industry influence in legislatures and even inside their own offices, he added.

He recalls that when he took up his post in Texas, he met with lawmakers in the Statehouse, some of whom were “unabashed” in their support of the insurance industry, warning “we’ll hurt your budget” if he went too hard on industry.

He didn’t play ball.

“If insurers are always happy, something is wrong,” said Hunter. “Insurance commissioners’ jobs are to hold them to account.”

Correction: This story was updated on Sept. 6 to correct the spelling of Connecticut Insurance Commissioner Katharine Wade.

To Insure More Poor Children, It Helps If Parents Are On Medicaid

Kaiser Health News:HealthReform - September 05, 2017

Efforts by Republican lawmakers to scale back Medicaid enrollment could undercut an aspect of the program that has widespread bipartisan appeal — covering more children, research published Tuesday in the journal Health Affairs suggests.

The study focuses on the impact of Medicaid’s “welcome-mat” effect — a term used to describe the spillover benefits kids get when Medicaid eligibility is extended to their parents.

Children were more likely to be enrolled in public health insurance programs — specifically Medicaid, which in some states is administered as an expansion of the federal-state Children’s Health Insurance Program — if their parents were also able to enroll, explained Julie Hudson, a senior economist at the federal Agency for Healthcare Research and Quality and the paper’s lead author.

Use Our ContentThis KHN story can be republished for free (details).

The findings highlight an underlying tension and a key relationship — parents’ insurance status and that of their kids — as Congress moves in coming weeks to reauthorize CHIP, before its funding expires at month’s end.

“Children’s health policy doesn’t exist in a vacuum,” said Benjamin Sommers, an associate professor of health policy and economics at Harvard University’s public health school. Sommers was not an author on the paper, but he did provide feedback on a preliminary draft. “We can’t discuss covering kids without considering what other policies are affecting parents.”

Among the most controversial aspects of the stalled Republican efforts to revamp the Affordable Care Act were provisions to limit Medicaid, the joint federal-state health care program for low-income people. But even if that effort is not revived, congressional Republicans have said they will continue their push to cut back the program.

In addition, many states are seeking waivers that would let them add other requirements to Medicaid — demanding beneficiaries undergo drug-testing or meet work requirements, for instance. Those, many analysts say, would likely reduce enrollment.

Such efforts could affect children who are eligible for Medicaid coverage.

The paper examines data collected from 2013 to 2015 by the Census Bureau’s nationally representative American Community Survey. It tracked kids up to age 18 who, based on family income, should qualify for Medicaid.

Researchers concluded that the children who benefited most from the welcome-mat effect lived in states that opted to pursue the ACA’s Medicaid expansion, where an estimated 700,000 kids who would have previously been eligible for Medicaid but were not enrolled gained coverage because their parents did, too.

“There’s no doubt that it’s the combination effect; when parents find out they’re eligible, it brings in the kids,” said Tricia Brooks, a senior fellow at Georgetown University’s Center for Children and Families, who was unaffiliated with the study. “I don’t think parents intentionally choose not to enroll their children. …  It’s going back to that lack of awareness, of understanding that children would be eligible on their own.”

To be fair, the study did not account for all CHIP programs or attempt to differentiate the various ways children could gain access to health coverage through Medicaid or CHIP.

Rather, noted Sommers, it highlights a broader pattern: “Public coverage for children … increased as the Affordable Care Act took effect.”

That gets at a more fundamental issue, many analysts suggested. The end goal of insuring kids — generally popular across the aisle — is difficult. The more controversial policy choices around adult coverage matter a great deal, too.

For instance, the Health Affairs study suggests that, had every state expanded Medicaid, 200,000 more kids would likely have gained coverage during the two-year period examined. And previous research has suggested that parents and children often have similar insurance statuses.

Brooks also pointed to simplified insurance applications, enhanced outreach and a larger push to enroll parents in health insurance, associated with the ACA broadly and the Medicaid expansion specifically. Those efforts, she said, all could have helped raise awareness about children’s eligibility for insurance as well.

“Children still are missed, and therefore direct outreach to families may be a really good thing, especially in those situations where parents are also eligible,” said Sara Rosenbaum, a health policy and law professor at George Washington University, who was not involved with the study. “It’s like added value. It’s a booster.”

Meanwhile, the White House has cut its budget for promoting private marketplace insurance, which some say would add to declines in adult coverage.

If those changes hit parents, the research suggests, the implications don’t stop there.

“The authors make a good case here that policies that are helping parents under the Affordable Care Act improve kids’ access — and moving the opposite way would affect their children negatively,” Sommers said.

KHN’s coverage of children’s health care issues is supported in part by a grant from The Heising-Simons Foundation.

California, Other States To Extend Obamacare Sign-Up Beyond Federal Limit

Kaiser Health News:HealthReform - September 05, 2017

California and several other states will exempt themselves this year from a new Trump administration rule that cuts in half the amount of time consumers have to buy individual health insurance under the Affordable Care Act.

In California, lawmakers are contemplating legislation that would circumvent the rule in future years, too.

The Trump administration’s rule gives people shopping for 2018 coverage on the federal exchange 45 days to sign up, from Nov. 1 through Dec. 15.

But in California and some of the other states that run their own exchanges — Colorado, Minnesota, Washington and Massachusetts, as well as the District of Columbia — consumers purchasing insurance for themselves this year will have extra time to make decisions.

Use Our ContentThis story can be republished for free (details).

In Colorado, for example, the sign-up period is from Nov. 1 to Jan. 12. In Minnesota, it will start Nov. 1 and run through Jan. 14. In Washington state, it is Nov. 1 through Jan. 15.

Consumers shopping for coverage in California’s exchange, Covered California, will still have the full three months they’ve had in recent years, starting on Nov. 1 and ending Jan. 31. Californians shopping for individual market plans outside the exchange will have those same three months to make up their minds.

“We want to make sure our consumers have the time they need to find the best plan that fits their needs,” said James Scullary, a spokesman for Covered California.

The rule that truncated the enrollment period for the federal exchange, published in April by the Centers for Medicare & Medicaid Services (CMS), gives state-based exchanges the ability to extend the amount of time allowed by tacking a “special” enrollment period onto the 45 days set by the federal government.

Because that flexibility is limited to 2018 coverage, California legislators are taking an extra step to keep the three-month enrollment period for 2019 and beyond. Assemblyman Jim Wood (D-Healdsburg) introduced legislation last week that would ensure a three-month enrollment window for consumers seeking coverage in 2019 and subsequent years.

“When the Trump administration issued its new … rules cutting the ACA’s open enrollment period in half, we knew we had to act,” Wood said. “Californians have enjoyed a three-month enrollment period for years, and this change could catch people off guard and not allow them to sign up in time. That would be a travesty.”

Health policy experts say the federal rule is a political attempt to undermine the viability of the Obamacare insurance exchanges.

“It’s no big secret that the Trump administration isn’t a big fan of the Affordable Care Act or the individual market that it created,” said Dylan Roby, associate professor of Health Services Administration at the University of Maryland. “There’s just this general intent of the administration to reduce enrollment, reduce … subsidies and make it a little bit harder for people to enroll.”

The shortened enrollment window was part of a so-called market stabilization rule rolled out by the Trump administration that also offers insurance companies concessions, including the flexibility to sell some health plans that cover less of the enrollees’ cost of care than currently required by the ACA.

California’s insurance commissioner, Dave Jones, expressed concern about the impact of a shortened enrollment period in a letter to the federal government in March, before the rule was finalized.

Jones’ letter cited research that shows younger people tend to sign up for health insurance toward the end of open enrollment, and that putting up barriers to their enrollment could reduce the number of healthy people in the insurance pool.

That would “needlessly destabilize the market” and would “result in increased premiums for those who do enroll in coverage,” the insurance commissioner said.

Shana Alex Charles, an assistant professor of health sciences at California State University-Fullerton, said the pushback by California lawmakers against federal attempts to shorten the enrollment period underscores the state’s commitment to having a marketplace that “actually makes sense.”

“If you want to maximize enrollment, you need to make sure people can get their paperwork together, and have the mindset and the time for people to complete the application,” she said.

This story was produced by Kaiser Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

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