Advocacy News: March 2024

Word From Washington

Federal Agencies

• According to the latest KFF Medicaid Unwinding Enrollment Tracker, more than 19 million Americans have lost Medicaid coverage since states were allowed to resume eligibility verifications following the COVID-19 public health emergency (PHE). At least 70 percent of Medicaid terminations continue to be for procedural reasons (such as not returning forms on time) and could still be otherwise Medicaid-eligible. HFA remains focused on mitigating erroneous coverage losses as both figures far exceed initial projections by KFF, the Urban Institute, and the Congressional Budget Office.
• The Centers for Medicare and Medicaid Services (CMS) has formally extended the special enrollment period (SEP) created during the COVID-19 “unwinding”, allowing individuals who lose Medicaid/CHIP coverage 60 days to transition to coverage through the Affordable Care Act (ACA) Marketplace. The “Unwinding SEP” was set to expire July 31^st but due to states adopting strategies to promote continuity of coverage, pausing procedural disenrollments to minimize wrongful terminations, and “other state-specific situations”, CMS has agreed to postpone the expiration until Nov. 30.
• CMS finalized regulations first proposed in 2022 to streamline eligibility and enrollment for more than 84 million Americans enrolled Medicaid, CHIP, or the Basic Health Program. The rules eliminate “red tape” and “outdated barriers,” especially the waiting periods and lockouts (for missing premium payments) that forced CHIP children in at least a dozen states (including Florida) to remain uninsured for significant periods of time. It also permanently removed annual or lifetime limits that some states relied upon in the past, consistent with the prohibition under the ACA. Consumer advocates also praised the rule for taking steps to protect enrollees during the “unwinding” of the PHE, including standardized requirements that states give renewal applicants at least 30 days to return documentation before terminating coverage and 90 days to submit documentation after being terminated. States must also retain documentation from applicants/enrollees for three years, helping to ensure fewer erroneous terminations due to missing paperwork.
• The Department of Health and Human Services (along with the Departments of Labor and Treasury) finalized regulations first proposed last summer to restore consumer protections against the use of short-term limited duration health insurance. STLDI was intended to fill only temporary gaps in coverage (i.e., when an individual transitions from one source of coverage to another). They are often considered “junk” insurance because they lack any of the protections under the ACA and are deceptively marketed with extremely low premiums that ultimately can leave consumers with tens of thousands of dollars in unexpected out-of-pocket costs. However, the Trump Administration extended limits on STLDI from three months to 12 months (or up to three years with renewals). The new rule reverts to the three-month limit (or a maximum of four months with renewals) and requires STLDI plans to notify consumers how they differ from ACA-complaint coverage.

Supreme Court

• The U.S. Supreme Court heard oral arguments on March 26^th in a case that could adversely impact access to hormonal therapies for women with bleeding disorders. The Biden Administration and the manufacturer of the drug mifepristone are challenging lower court decisions that effectively invalidated the 2000 approval by the Food and Drug Administration of the commonly prescribed abortion medication (following the Supreme Court reversal of the landmark Roe v. Wade) However, both liberal and conservative justices appeared skeptical that the physician plaintiffs in Alliance for Hippocratic Medicine v. FDA had “standing” to bring the case and appear ready to dismiss it on procedural grounds (although conservative justices suggested that states would have standing to challenge the drug’s approval if the case were refiled). HFA has signed onto an amicus curiae (or “friend of the court” brief) filed by patient and provider groups supporting the Biden Administration’s appeal, given that mifepristone has several other uses, including as a safe and effective first-line hormonal therapy for menstruating women with bleeding disorders.

Congress

• President Biden signed a series of appropriations bills passed during March that fund federal government agencies through the remainder of fiscal year 2024 (which ends September 30^th). The legislation ends the budget impasse that had forced Congress to issue several short-term spending resolutions since last September in order to avoid a federal government shutdown. It also forestalls any debate over raising the debt ceiling until 2025.

State of the States

Oregon becomes first state in 2024 to pass protections against copay accumulator adjusters

Oregon Governor Tina Kotek (D) signed legislation unanimously passed by the House and Senate that protects consumers in state-regulated health plans from harmful and discriminatory copay accumulator adjuster programs (CAAPs).  A total of 19 other states (plus DC and Puerto Rico) have already acted to prohibit CAAPs and legislation remains pending this session in several states including California, Maryland (where the House and Senate passed differing versions), Massachusetts, Missouri, Rhode Island, and Vermont.  A new report from The AIDS Institute shows that two-thirds of ACA Marketplace plans nationwide currently allow for some form of CAAPs in their plan documents.

Despite new momentum, Medicaid expansion stalls in opt-out states

According to the latest data from the North Carolina Department of Health and Human Services, more than 385,000 have enrolled in the Medicaid expansion that went into effect on December 1^st. 

The success in North Carolina (where more than 1,000 residents are signing up per day—twice as fast as other newly-expanded states) generated significant momentum in several of the remaining nine states continuing to “opt-out” of the Affordable Care Act expansion. However, those efforts appear stalled as their legislative sessions near the end.

Mississippi

Consumer advocates had the highest hopes for Mississippi after the House overwhelming passed legislation to fully expand Medicaid under the ACA, even if the federal government refused to approve its request work reporting requirement. However, despite the veto-proof margin, the measure continues to face opposition from Governor Tate Reeves (R) and key Senate Republicans. As a result, the Senate passed only a limited Medicaid expansion, which includes a more stringent work requirement that cannot be removed if not federally-approved.

With these major differences still unresolved, it remains unclear if the bills can be reconciled without losing the two-thirds support in each chamber that would be needed to override the governor’s promised veto.

Kansas

Medicaid expansion legislation was heard in committee in Kansas for the first time in four years (H.B. 2556).  However, the measure failed to advance despite the backing of Governor Laura Kelly (D), the Kansas Hospital Association, and more than 900 written testimonials from supporters.

Georgia

A measure to fully expand Medicaid in Georgia failed in committee on a 7-7 vote. According to KFF Health News, the more limited Medicaid expansion authorized by Governor Brian Kemp (R) has enrolled only about 3,500 Georgians since it started last July (or a small fraction of the 25,000 the governor projected for year one). In addition, Georgia already spent over $26 million for this “Pathways to Coverage” expansion with 90 percent of expenses going for administrative costs—due largely to a work reporting requirement that has led to a backlog of 45 percent of program applications. By contrast, fully expanding Medicaid under the ACA would extend coverage to nearly 360,000 Georgians and bring in more than $700 million in federal matching funds over the first two years.

New Mexico increases funding and availability of state premium subsidies

New Mexico Governor Michelle Lujan-Grisham (D) signed H.B. 7 this month, which increased funding the Healthcare Affordability Fund for the next two years.  According to the Superintendent of Insurance, the Fund has already saved New Mexicans enrolled in the ACA Marketplace more than $45 million in lower premiums since it was created in 2021. The state subsidy program is also largely responsible for nearly 72 percent of Marketplace consumers in New Mexico being able to enroll in more generous gold-tier coverage, by far the largest share nationwide.

Starting in 2025, the legislation authorizes the Superintendent to use the Fund to subsidize coverage for those not eligible for the Marketplace or Medicaid due to immigration status.

Illinois House advances governor’s protections against step therapy, short-term health plans

The House Human Services Committee has approved a “monumental” package of health reforms proposed last month by Governor J.B. Pritzker (D).

The Health Care Consumer Access and Protection Act (H.B. 5395) would make Illinois the first state in the nation to ban health plans from imposing prior authorization requirements on inpatient mental health services for both children and adults. In addition, it would strengthen the state’s guardrails against step therapy (or “fail first”) protocols, impose strict network adequacy and transparency standards, establish a rate review process for large-group health plans, and altogether ban the sale of short-term limited duration health insurance (see new federal rules on STLDI above).