Open letter on health insurance, round 3

April 21, 2017

Dear Congressman Faso,

“The plan gets better and better and better, and it’s gotten really, really good, and a lot of people are liking it a lot.”

Those are the words of Donald Trump, and I'm wondering if you can help me interpret them.

Is he talking about the MacArthur Amendment to the AHCA?

Insurance Market Provisions 

The MacArthur Amendment would:

• Reinstate Essential Health Benefits as the federal standard

• Maintain the following provisions of the AHCA:

o Prohibition on denying coverage due to preexisting medical conditions

o Prohibition on discrimination based on gender

o Guaranteed issue of coverage to all applicants

o Guaranteed renewability of coverage

o Coverage of dependents on parents’ plan up to age 26

o Community Rating Rules, except for limited waivers

 It says, "Maintain the following provisions of the AHCA, but the things that follow are all part of the Affordable Care Act, aka, Obamacare. Is this a typo on Politico's part, or is Rep. MacArthur trying to imply that the original AHCA actually had all these things that, it turned out, people really liked about the ACA?

So is the AHCA getting better and better and better because it's morphing in the direction of being more and more like the ACA, just with a different name?

And what's that language about "reinstating" Essential Health Benefits? If the amendment said, "re-stating," it would be accurate. The EHB's are part of Obamacare, and Congress famously hasn't yet repealed that, so it's still the law and the EHB's are still the federal standard. You can't reinstate something that hasn't been uninstated.

Again, a typo by Politico, or is Rep. MacArthur trying to bum-fuzzle people as to what the ACA is and what the AHCA would be?

There's that mention of waivers in the last line quoted above. Let's see what that's about.

The amendment would create an option for states to obtain Limited Waivers from certain federal standards, in the interest of lowering premium costs and expanding the number of insured persons. States could seek Limited Waivers for:

• Essential Health Benefits

• Community rating rules, except for the following categories, which are not waivable:

o Gender

o Age (except for reductions of the 5:1 age ratio previously established)

o Health Status (unless the state has established a high risk pool or is participating in a federal high risk pool)

So under certain circumstances (we'll look at those below), you can get out of some of the community-rating rules - in other words, you can charge some people more than others.

As I tried to explain in my first and second letters to you on health insurance, if you break down community rating, you're undermining the promise of providing coverage for pre-existing conditions. Well, there will be coverage, it just won't be affordable by most households.

Oh, wait, states can't get a waiver that would allow insurers to charge more for Health Status (i.e., pre-existing conditions) unless they've got a high-risk pool. So that should be fine. (In case you don't feel like clicking the links, they go to sources explaining why high-risk pools are essentially a failure of a policy.)

And it's nice that the waiver on age will only let states come down (i.e., offer seniors a more favorable premium ratio than the AHCA otherwise specifies). But that implies that it is still moving from the ACA's 3:1 to the 5:1 that was in the bill you never voted on.

Unambiguously nice is that there will be no waivers allowing insurers to charge women more than men (nor men more than women). Though the value of that protection is very little if, for example, you get a waiver allowing insurers to get out of providing gynecological care.

Is that the part that a lot of people are liking a lot?

Finally (you knew this had to end sometime, right?), there are the requirements for getting a waiver:

Limited Waiver Requirements

States must attest that the purpose of their requested waiver is to reduce premium costs, increase the number of persons with healthcare coverage, or advance another benefit to the public interest in the state, including the guarantee of coverage for persons with pre-existing medical conditions. The Secretary shall approve applications within 90 days of determining that an application is complete.

 Sounds reasonable. You can get a waiver if it will reduce premium costs.

Or if it will increase the number of persons with coverage.

Or if it will "advance another benefit to the public interest in the state."

But note the word "or": you can do any one of those things, and you're fine. And the first of those things is very vaguely worded.

Reduce premium costs for whom? For everyone? If this is the accurate language of the amendment, that's not actually required. You can reduce premiums for some people by establishing a high-risk pool and then getting a waiver so that people with pre-existing conditions don't need to be under the community-rating umbrella. And Presto! Premiums go down for many people, while those with pre-existing conditions end up right back where they were before Obamacare.

That will probably mean that fewer people will actually have coverage, but the amendment allows that, because of the magic "or": you don't have to reduce premiums and expand coverage, just one or the other.

But wait, you don't even need to do that. "States must attest that the purpose of their requested waiver is to ..." (emphasis added). They don't have to demonstrate that the effect will be to do certain things; they merely have to attest that the purpose is to do those things.

What if they're lying?

Apparently that's fine, because "The Secretary shall approve applications within 90 days of determining that an application is complete." (emphasis added)

If you complete your application and attest that its purpose is some potentially meaningless combination of those conditions linked by "or," you get your waiver.

Is this the part of the plan that's really, really good?

Or is the really, really good part the implication that it cuts subsidies and Medicaid just as drastically as the original AHCA? I'm not sure if that's what it does, but since the text provided as the "MacArthur amendment" doesn't say anything about that aspect, it seems to be the case.

If this amendment comes before your committee, will you allow it to move forward like you did the original version of the AHCA, or will you use your leverage to demand that a decent bill be drafted before allowing it to proceed?

(Before sending the physical copy, I appended the following paragraph.)

Are you going to take the time to learn how health insurance works, or are you going to vote based on party sound bites? I recognize that this letter has a less-than-respectful tone, but you were apparently prepared to vote for the AHCA last month, before it got pulled from the floor for lack of support. After making nice noises about protecting people, you were prepared to vote for a bill that would have devastated health care for millions of people across the country, and stripped insurance coverage away from one out of every eight of your own constituents. The lack of respect implicit in those actions is far greater than anything I would be capable of summoning in words alone.