Independent Health is closely following plans by the Trump Administration and Congress to address the future of the Affordable Care Act (ACA) and will keep our customers up-to-date on developments. We provide this latest overview in our occasional series of ACA updates.

April 17, 2017 Update:
Congressional activity; and focus on prescription drug costs

Uncertainty continues in Washington regarding the future of the Affordable Care Act following the House Republicans’ withdrawal of its reconciliation bill, known as the American Health Care Act (AHCA), from a full House of Representatives’ vote on March 24.

After initial comments by President Trump that he would move on to other legislative issues following the cancellation of the vote, there appears to be renewed efforts by the White House and Republican members, who were prepared to vote against the AHCA, to find a path to achieving a reconciliation bill to repeal the ACA. Passage of a reconciliation bill is one phase of a three-phased approach to repealing and replacing the ACA. The second phase, introducing legislation that impacts specific policies within the ACA is also being addressed as many bills are being considered in both the House and Senate, including:

  • The Small Business Health Fairness Act, which establishes a new regulatory framework and certification process for association health plans (plans offered through business associations). The House passed this bill, which is now going through Senate committees.
  • The Self-Insurance Protection Act, which excludes from the definition of health insurance coverage medical stop-loss insurance obtained by plan sponsors of group health plans. This bill also was passed by the House.
  • Protecting Access to Care Act, which addresses medical liability reform.
  • The Patient Freedom Act of 2017, which would allow states to remain under the ACA if they choose.
  • Health Care Options Act, which would allow people with an ACA subsidy but no health insurance on their ACA exchange to use their ACA subsidy to purchase health insurance outside of an ACA exchange, as long as the insurance is approved by the state for sale in the individual market.

The other approach looks at administrative actions that can be taken to unravel the provisions of the ACA. The Secretary of Health and Human Services (HHS), Tom Price, has found there are 1,442 instances where the Secretary has authority to determine which provisions, like essential health benefits, will be implemented. HHS recently issued a rule that seeks to stabilize the marketplace by changing some the ACA rules, like requiring verification for special enrollment periods and shortening the open enrollment period for 2018.

ACA Provision Review
As President Trump’s administration and Congress consider alternatives to replace the ACA, proposals should address key components, such as:

Drug Costs
Prescription drugs are an important part of the health care system and patients rely on medicines to keep them healthy. Unfortunately, prices for prescription drugs have soared in recent years, with the price of a single medicine often exceeding an average American’s annual income, putting a severe burden on employers as well as on consumer premiums. Not only are drug manufacturers launching products with high prices, they are routinely raising the prices of existing drugs — even decades-old drugs — by double-digit rates. Published data from the Centers for Medicare and Medicaid Services show that spending on prescription drugs largely outpaced spending in other areas of health care, increasing 9 percent to $324.6 billion nationwide in 2015.

Health care costs are a major concern for New York residents and businesses, as well as state lawmakers and regulators. The continued increase in the cost of health care puts enormous strain on local and state budgets and inhibits the ability of employers to create and grow jobs. In fact, New York health care spending is 22 percent higher than the rest of the nation.

To improve access to prescription drugs and to make new treatments more affordable, health care stakeholders should promote policies that preserve needed innovation and competition, while also promoting greater transparency to improve the value of prescription drugs for patients.

There has been some movement in Congress and the New York State legislature to address rising drug costs. There were three bills recently introduced in Congress:

1) S. 637/ Creating Transparency to have Drug Rebates Unlocked (C-THRU) Act

a.Mandates public discloser of PBM negotiated prices

2) H.R. 1316/ Rx Price Transparency Act

a.Restricts types of PBMs that MA and Part D plans can contract with

b.Mandates MA and Part D plans disclose private pricing sources for Rx claims, and a drug pricing appeals process

3) H.R. 1038/ Improving Transparency in Medicare Part D

a.Restricts Part D plans from making retroactive, negative adjustments to reimbursements for pharmacy-based claims once they are deemed to be “clean”.

b. (A "clean claim" is a Medicare claim that is free of defects such as incomplete documentation.)

In New York State, a way to combat rising drug costs was addressed the State budget that was passed last week. The State will attempt to limit the growth of Medicaid drug spending by establishing a “Medicaid drug cap” as a separate component of the Medicaid global cap.

As with all health care costs, addressing pharmacy costs requires a collective effort of all stakeholders, including initiatives that promote quality, access and proper usage. At Independent Health, one such initiative to address the proper usage of medications was a unique medication adherence pilot project in collaboration with the Pharmacists’ Association of Western New York. This pilot project resulted in improved medication adherence through direct pharmacist-to-patient interactions.

As health care and pharmacy costs continue to rise, Independent Health will continue to focus on initiatives and programs aimed at offering quality, accessible and affordable coverage.