5 health care predictions for 2018

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President Trump gave an interview to the New York Times that included this very rambling sentence on association health plans:

So now I have associations, I have private insurance companies coming and will sell private health care plans to people through associations. That’s gonna be millions and millions of people. People have no idea how big that is. And by the way, and for that, we’ve ended across state lines. So we have competition. You know for that I’m allowed to [inaudible] state lines. So that’s all done.

Lucky for all of us, my VoxCare co-writer Dylan Scott has a great piece on what association health plans are, and how the Trump administration recently used an executive order to expand them.

2018 health policy predictions!

Some people like to start a new year with resolutions. I, however, have a bit of a different tradition: trying to figure out what the heck is going to happen in health care.

This past year has been full of unpredictable twists and turns in health policy, right down to Sen. John McCain’s (R-AZ) 2 a.m. thumbs-down vote that sunk the Senate health care bill.

So what does 2018 have in store for us? Here is a far from complete list of what I’m expecting in the new year, and what I’ll be watching as 2018 begins.

Congress revisits Obamacare. Like that terrible habit you can’t quite kick, I’m guessing we see at least one more attempt at a major Obamacare overhaul bill in the new year.

Yes, I know Senate Majority Leader Mitch McConnell has said it’s time to move on. But remember what happened when House Speaker Paul Ryan declared Obamacare “the law of the land,” moments after their first repeal efforts failed? Republicans have found it really hard to quit the Obamacare repeal fight after promising action for nearly a decade.

And next year may be even harder to quit. A few weeks ago, Axios’s Sam Baker made a convincing argument for why the tax bill actually makes it more likely that Republicans will work on health care in 2018. The repeal of the individual mandate may cause some state marketplaces to fall into collapse, as insurers no longer want to sell in an environment where healthy people are not required to purchase coverage.

The ensuing mess may make it really hard for Congress to avoid doing something to stabilize the marketplaces. Maybe it’s Alexander-Murray, maybe it’s something we haven’t seen yet, maybe it’s not even branded as Obamacare repeal but as Republicans creating their own health care program. Whatever it is, I think there is a good chance that the Ghosts of Health Care Bills Past keep stalking around Capitol Hill for another year.

Some states work to pass their own individual mandates. The new tax law ends the Affordable Care Act’s requirement that nearly all Americans purchase health insurance coverage or pay a fine. In response, I’m expecting to at least a few states that support the health care law work to pass their own, state-level mandates. So far, we’ve seen some rumblings of action from California, Maryland, the District of Columbia and Washington State (and Massachusetts, of course, already has a mandate from its 2006 reforms).

I’m expecting to see a few more states that manage their own marketplaces try to take action on this issue, although it’s anyone’s guess which ones. Not all of these efforts will pass — and some might test out different ideas for encouraging people to buy health insurance, like a late enrollment penalty or higher premiums for those who have a break in coverage.

Medicaid sees big changes — ones the Obama administration blocked. About a half-dozen states want to make some big changes to Medicaid. They want to add in things like work requirements, small premiums for low-income enrollees, and (in the case of Wisconsin) drug testing for beneficiaries.

These waiver requests have been sitting with Medicare administrator Seema Verma, many for months now. Verma is generally supportive of these approaches to Medicaid policy. She gave a speech this fall to the National Association of Medicaid Directors in which she said this:

For people living with disabilities, CMS has long believed that meaningful work is essential to their economic self-sufficiency, self-esteem, wellbeing, and improving their health. Why would we not believe that the same is true for working-age, able-bodied Medicaid enrollees?

Believing that community engagement requirements do not support or promote the objectives of Medicaid is a tragic example of the soft bigotry of low expectations consistently espoused by the prior administration. Those days are over.

I’ve been a bit surprised that these waivers haven’t been approved yet. Keen observers of the Medicare agency have argued that staff have their hands quite full, between Obamacare repeal efforts and a slew of executive orders and new regulations that they’ve put out in 2017. In any case, I’m certainly expecting to see movement on these waivers next year — and that would mean really significant change for Medicaid. Never before has the federal government required low-income Americans to work in order to receive their federal health benefits. But that is likely about to change.