State Customization Of Affordable Care Act On Horizon

May 20, 2015

Cheryl Smith Gardner, Executive Director Arkansas Health Insurance Marketplace Board and board member Mike Castleberry speaking to a legislative committee.
Credit Jacob Kauffman / KUAR

A section of the Affordable Care Act – called a 1332 waiver – is being hailed by one of the legislative architects of the private option and the director of the Arkansas Health Insurance Marketplace Board as a path toward consensus in a Legislature riddled with uncertainty over healthcare. 

The Arkansas Health Insurance Marketplace Legislative Oversight Committee turned its attention on Wednesday to the "State Innovation Waiver." 

The federal healthcare law allows states some flexibility through the 1332 waiver to use federal dollars to build alternative healthcare delivery systems. Since the ACA passed in 2009 various stages of proposals throughout the nation have ranged from single-payer like incarnations to more consumer driven approaches. States can begin applying for the waiver in 2017. But there are limits.

AHIM Director Cheryl Smith Gardner told the committee and re-iterated afterward that for a waiver to be approved by the U.S. Department of Health and Human Services certain conditions of coverage must be met.

“Coverage has to be budget neutral, has to be at least as comprehensive…but there’s wiggle room in what is comprehensive…and you have to cover as least as many people as would have been covered under the ACA,” said Smith Gardner.

A 40 plus page report was compiled by AHIM and their consultant, Public Consulting Group, titled Section 1332 Waivers and the Future of Arkansas Healthcare Innovation and presented to the committee. The five year waivers allow major pillars of the ACA to be adjusted or all together removed as long as a state can prove it can use federal dollars as effectively. Eliminating the individual mandate, employer mandate, exchanges, subsidies, and a host of other changes could be possible, as long as certain coverage levels obtained by ACA policies and programs are maintained.

Rich Albertoni with PSC walked legislators through some of the major changes possible under a 1332 waiver and possible combinations with other waivers to the Medicaid program - like Arkansas used in 2013 to create the private option adaptation of Medicaid expansion.

“The way the boundaries are largely drawn right now is by income,” said Albertoni. “I think in Medicaid what we’ve seen in the private option already is that health status or work readiness are also categories that could be useful ways to redefine these sorts of things. Maybe if folks are low income but are seeking jobs in the market they could be better served in the marketplace instead of through the Medicaid program.”

State Senator David Sanders, the committee’s co-chair, said what he characterizes as successes in the private option - Arkansas’s version of Medicaid expansion - informs the direction the state should take when crafting a 1332 plan.

“Some of the things that we’ve done through our premium assistance program, known as the private option, we’ve proven some things that had yet to be proven. That is to say, that premium assistance has worked,” said Sanders.

The Republican legislator said shifting more people covered under federally-run health plans to privately-run plans is a tenant for his vision of Arkansas healthcare under the Affordable Care Act.

“I am very much in favor of a consumer based model. I fundamentally believe as a matter of policy we make the wrong decision when we tell poor people, you are going to be segregated into a Medicaid program and excluded from the private insurance markets. That has what has informed me since day one,” said Sanders.

But he acknowledges there is work to be done both in terms of crafting a plan and building support by 2017.

“I’m not sure it’s settled for some in terms of the mode that we’re going to provide for care,” said Sanders. “But if you come to that place where you say coverage is important then you can have the debate about what level of coverage, and how much should it cost, and what can we do to drive down the cost and deliver quality care."

“I have some members from our Republican caucus that are actually arguing going back to a fee for service based system which was originally contemplated in the affordable care act and not to a premium assistance model which has been the iron-clad conservative proposal for decades,” said Sanders.

The number of chairs filled by legislators by the meeting’s end suggests disseminating the intricacies of uncharted state relationships with the federal healthcare apparatus among state legislators is a long-term task. All of it is on the pretense that the expanded population of people covered and receiving coverage support under the ACA receive and equitable level of care in a state crafted plan. For some Republicans in the committee like Rep. Josh Miller it has at least in the past been difficult to accept any continuation of the ACA.