WASHINGTON (FRONTLINE MEDICAL NEWS) – Physicians testifying before the Senate Health, Education, Labor & Pensions Committee offered recommendations that are generally in line with the narrow, focused legislation to stabilize the individual health insurance markets that Chairman Lamar Alexander (R-Tenn.) is hoping to introduce early in the week of Sept. 17.

Two key provisions of Chairman Alexander’s plan are extending the cost-sharing reduction (CSR) payments to insurers through the end of 2018 and providing additional flexibility to the process that allows states to come up with alternatives to the Affordable Care Act mandates.

After three previous hearings on the subject, Chairman Alexander said during a Sept. 14 hearing that a third option is being considered: allowing consumers aged 30 years or older to purchase so-called ACA copper plans that generally provide catastrophic coverage with a low premium and a high deductible. Under current law, copper plans are available only to people aged 29 years and younger.

Manny Sethi, MD , president of Healthy Tennessee, said he favored repealing and replacing the ACA but offered suggestions to fit the current legislative landscape.

“We must take three steps immediately,” Dr. Sethi, an orthopedic trauma surgeon, testified. “First, in order to stabilize the insurance markets, we must continue the cost-sharing reduction program. Premiums are rapidly rising as insurers fear they will be left bearing the cost. These soaring costs are forcing young members out, saturating the market with higher-need and higher-cost patients and further escalating prices in a troublesome cycle.

“Second, we must quickly create risk pools for those individuals with serious chronic conditions, allowing more affordable coverage options for young, healthy citizens,” Dr. Sethi continued. “Third, I believe a one-size-fits-all plan from Washington, D.C., doesn’t meet the needs of Tennesseans. Open the door for innovation, and allow more flexibility for states to create their own insurance products. For example, a catastrophic plan should be available regardless of age or income status, which is currently not the case.”

Opening the catastrophic plans to all would help bring people into the individual market, even if they don’t have access to any government subsidies, he said.

“Meeting with patients … I do believe that creating a catastrophic plan open to all ages, all incomes, I think would bring younger folks, and people in general, into the insurance market because I think that’s the problem,” Dr. Sethi said. “You don’t want to pay more for your insurance than you do for your home mortgage. When you do that, something’s wrong.”

Susan Turney, MD , CEO of Marshfield (Wisc.) Clinic Health System, offered similar suggestions. She called for fully funding CSR payments for 2018 and beyond and also recommended creating a reinsurance program, establishing continuous coverage rules that encourage people to get and maintain coverage, enhancing risk adjustment for payments to carriers, and reinstating federal funding for outreach that was recently cut by the Trump administration.

But she also stressed a longer-term goal of how care is delivered, especially in rural areas.

“As we look at this short-term fix to a relatively small group of insured, we have to start thinking differently about how we provide care. The care delivery model needs to be above the payment system, and, once we figure out how to take care of our communities, we can then look differently at the way we support the practices who provide those services,” Dr. Turney said. “Most people don’t ask to get sick. We need to take care of them, and we need to figure out the best way to do that.”

Physicians’ organizations including the American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, American Congress of Obstetricians and Gynecologists, American Osteopathic Association, and American Psychiatric Association, submitted a joint statement to the committee that advocated ensuring CSR funding through at least 2019, continuing reinsurance programs, continuing community outreach programs, and expanding public choice through a public option in all exchanges markets.

Chairman Alexander stressed that, in order for this narrowly focused bill to have a chance at passing, it will require a little compromise from both sides of the aisle.

“To get a result, Republicans will have to agree to something – additional funding through the Affordable Care Act – that some are reluctant to support,” he said. “And Democrats will have to agree to something – more flexibility for states – that some may be reluctant to support. I simply won’t be able to persuade the Republican majority in the Senate, the Republican majority in the House, and the Republican president to extend the cost-sharing payments without giving states meaningful flexibility.”

He stressed that the flexibility he is looking for in the 1332 waiver program will not alter consumer protections that are in place, including the ban on charging more for preexisting conditions, guaranteed issue, no annual or lifetime caps on benefits, and allowing those under 26 years of age to remain on their parent’s policy.

“Our goal is to see if we can come to a consensus by early next week so we can hand [Senate Majority Leader Mitch] McConnell and [Senate Minority Leader Chuck] Schumer an agreement that Congress can pass by the end of the month that would help limit premium increases for 18 million Americans next year and begin to lower premiums after that, and to prevent insurers from leaving the markets where those 18 million Americans buy insurance.”


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