A panel charged with discovering the problems that have led to the instability of the insurance markets in Missouri took its first shot at tackling the obstacle Wednesday in Jefferson City.
The Interim Committee on Stabilizing Missouri’s Health Insurance Markets includes five Republican and two Democratic state House members.
Chairman Justin Hill, R-Lake St. Louis, conducted the hearing, offering several big ideas that would change how the health care system operates.
Chief among them would be applying for a waiver, which would give the state flexibility to restructure its health care markets. It would allow Missouri to drop key requirements under the Affordable Care Act (ACA) in order to experiment with different health coverage models.
24 states have considered legislation to “kick-off” the waiver application process, which became available January 1st of this year. A bill in the Missouri legislature to formally apply failed to advance in the last session.
Hill says he’s anxious to get input from all industries who would be impacted by a waiver. “I’m hoping to get opinions of all the stakeholders that are involved in this space so that we try something new, something that will be effective,” said Hill. Formulating a process to apply for a waiver is part of the interim committee’s responsibility.
Both Republican and Democratic leaning states are looking at the option, known as an Innovation Waiver, to make deviations from the health care law’s requirements.
Chris Molendrop, who represents the Missouri Hospital Association (MHA) in the legislature, thinks the number and kinds of changes Missouri makes in its waiver request will determine whether it’s workable.
“Will this be about the individual insurance market?” said Molendorp. “Will this also be about our Medicaid plan? Will this change the basic structure of insurance policies that are offered in the Show-Me State? The devil is in the details. And the legislature will have a lot of work to do in crafting the proposal.”
The ACA includes guardrails limiting how the waivers can be used by states. They must provide coverage that is at least as comprehensive, affordable and available as conditions would be without a waiver.
Another prospect brought up by Hill was a change to the ACA’s essential health benefits requirement proposed by the Trump administration. The plan would let states opt out of some of the 10 required services insurers would have to cover.
Hill thinks it would be appropriate to drop benefits that drain a disproportionate amount of money from the system. “Once you give somebody something, they don’t want to lose it of course. We understand that. But if we can make the case that that essential benefit is turning the risk pool upside down, and it’s for the greater good, then who would be against that.”
The proposed change to essential health benefits is currently in a comment period, and won’t go into effect for months if not a year, if it’s adopted.
The required benefits under the ACA are emergency services, hospitalization, mental health services, prescription drugs, rehabilitation, lab services, preventative care, pediatric services, outpatient care and maternity care. The Trump administration says its proposal offers states more flexibility in handling healthcare.
Democrats have typically been resistant to allowing states to drop any essential services, thinking such a policy would lead to stripped down plans being offered on the ACA exchanges.
Selling such packages, Democrats contend, could leave people without coverage when they need it. They further contend it could isolates people with preexisting conditions into a category where they’re coverage would skyrocket in price. Molendorp with the MHA says the advantage or detriment of letting states downsize essential benefits is yet to be determined.
“If the states seek more flexibility, the is legislature going to have to fully vet what that means. What coverages will be omitted? What coverages may be added? What are truly essential coverages for a typical Missouri policyholder? And the devil will lie in the details.” Molendorp is a former three-term Republican member of the Missouri House from Belton.
Hill also thinks the committee should discuss the possibility of establishing a state-run exchange within the ACA. He says Washington is the gold standard for exchanges that other states are turning to.
“It’s so good that whenever you enroll in a plan in Washington, they automatically assign you an insurance agent,” Hill said. “So, you actually have someone you can call and say “OK, help me understand this.’”
Although the health exchanges are facilitated under the ACA, also known as Obamacare, Hill prefers not to associate the two together. “If you’re talking about an exchange where someone can go and buy a plan, I don’t think that’s Obamacare. That’s just using the internet to market health insurance.”
Currently, a majority of states offer healthcare on the exchanges provided through the federal government.
Other concepts brought up by Hill during the hearing included “reinsurance”, which would assist insurers who face high costs from outliers in their insurance pools.
Part of the urgency in addressing options for health care delivery is driven by the state of the exchange in Missouri. Only three companies are offering policies in 2018; Cigna, Anthem and Centene.
Centene is entering the state’s marketplace for the first time, although it has a separate Medicaid managed care contract in Missouri. Cigna and Anthem have proposed major rate increases of 42% and 36% respectively for 2018.
Hill plans to conduct at least two more hearings of the Interim Committee on Stabilizing Missouri’s Health Insurance Markets. The panel must have a report to present to the full legislature in time for the upcoming legislative session in January.