Quality Health Insurance Coverage
Access to affordable, high quality healthcare is essential for people with multiple sclerosis to live their best lives. Health insurance coverage is vital for people to be able to get the care and treatments they need.The National MS Society believes that plans for a new healthcare insurance system must happen at the same time as a repeal of the Affordable Care Act. The Society’s positioning and additional information on quality health insurance coverage is outlined in the following Q&A.
Advocacy Positioning Q&A
Legislative/Executive Process and Procedures
How Do I Get Engaged
Additional information
Q&A
Q: What is the Society’s position on repealing or replacing the Affordable Care Act?
A: The Society supports policies that promote access to affordable, comprehensive health coverage. In recent weeks, the Society has added its name to numerous letters to Congress and other policymakers urging them not to repeal the Affordable Care Act (ACA) unless a replacement for it is enacted assuring a health coverage system that is at least as effective as the current law. Repealing the ACA without an adequate replacement endangers millions of people with a chronic illness or disability who are now protected against the discriminatory practices of insurers before they were prohibited by the ACA.
How is the Society advocating on this issue/engaging on this issue?
Advocating for accessible, affordable and comprehensive coverage for people with MS is a top priority this year and the Society will employ robust efforts to make the voices of people with MS heard. This issue will be a priority issue at the Society’s Public Policy Conference, numerous action alerts will provide the opportunity for people with MS to inform their elected officials of their experiences and we will gather the experiences of people with MS to frame the Society’s positions and messaging. Additionally, the Society will work in partnership with other organizations within the chronic illness and disability community. You can stay up to date with the Society’s efforts at
What is the 30 second elevator pitch of the Society’s position on health coverage?
People living with MS need the ABCs of health care coverage. Coverage must be:
- Affordable- premium assistance, annual caps, elimination of lifetime caps and reasonable out-of-pocket costs spread throughout the plan year
- Befor everyone- including those with pre-existing conditions
- Comprehensive- meaningful, comprehensive coverage to meet the needs of people with complex health conditions and throughout the lifetime of living with MS
The Society also believes that transparency across the healthcare system and investing federal funding in research to understand value, quality, and patient-centered care will support an improved healthcare system with the potential for better health and financial outcomes.
How does the Society’s Make Medications Accessible initiative integrate with advocacy on quality health insurance coverage?
As stated by Sean Spicer, the press secretary, “Getting ahold of the cost of prescription drugs… will allow [people] greater access to health care.” There are opportunities to advocate for affordability and access to medications as part of advocating for quality health insurance coverage. Woven through the components of quality health insurance coverage for people with MS are vital aspects of affordable access to medications. For example:
- affordable coverage includes reasonable deductibles and out-of-pocket costs, and spreading those costs throughout a plan year
- comprehensive benefits includes access to needed medications
- transparent coverage includes transparency of healthcare costs, transparency throughout the healthcare system, easing barriers to care, patient understand of and benefitting from rebates and an effective and clear appeals process
- quality and value includes understanding and paying for the value of medications and including patient-centered care as a critical component of the health system
What comprehensive benefits are important for people with MS to achieve optimal health?
Quality MS care requires a comprehensive treatment approach with access to a coordinated team of experts, medicines, equipment and supports needed to achieve the best outcomes. This includes access to a variety of specialists (neurology, neuro-ophthalmology, urology…), medications, diagnostic and disease monitoring tests and assessments, rehabilitation therapies, mental health services and durable medical equipment. Access to long-term supports and services, wellness services and interventions as well asneurocognitive evaluation and interventions and cognitive therapy are important for optimal health.
What is a high risk pool?
A high risk pool offers health insurance coverage to people with pre-existing conditions who have been denied other health insurance because of their existing medical condition. These pools offer health insurance coverage that is subsidized, usually by a state government. Health insurance through a high risk pool may be more expensive and more limited in coverage than typical insurance options because people with expensive healthcare needs are all grouped together rather than spreading costs across a more balanced population with high and low healthcare needs.
Q: What other some of the major ideas for replacing the Affordable Care Act?
High Risk Pools
High risk pools were programs established by certain states that offered subsidized health insurance coverage to individuals excluded from traditional health insurance plans due to a pre-existing condition or other reasons. Most of the 35 state high risk pools ceased operating after insurers’ were prohibited from excluding people with pre-existing conditions from coverage by the ACA. People who were previously enrolled in high risk pools have transitioned into other health plans now available to them.
Here are some important facts about the high risk pools of the past:
- High-risk pools covered only 226,615 people in 2011—a mere fraction of the number of people with pre-existing conditions.
- Premiums for coverage in state high-risk pools were typically 150%-200% of standard rates for healthy individuals.
- Almost all state high-risk pools excluded coverage for pre-existing conditions for 6 to 12 months, making health coverage effectively useless during that period.
- Nearly all state high-risk pools (33 out of 35) had lifetime dollar limits on coverage, most between $1 million-$2 million. 13 had annual dollar limits on coverage, which could cap people’s coverage to as low as $75,000 in care a year.
- High-risk pools were expensive for states: In 2011, states had to finance $1.2 billion in net losses to cover costs that exceeded money brought in through premiums.
Q: What is the Society’s position on high risk pools?
A: In the past, high risk pools were often a last resort for obtaining health coverage among people living with MS. But the coverage was problematic, and often included waiting lists for coverage and care, annual deductibles as high as $5,000, limited benefits and a lack of access to critical specialist care. The Society is opposed to high risk pools in constant risk of being under-funded as they segregated people with the greatest need for health care and coverage. Patient protections like prohibiting insurers from excluding people with pre-existing conditions or charging them more, eliminating lifetime caps on insurance policies and annual dollar limits on benefits, and equitable methods for pricing coverage are essential for people with complex, lifelong and high-cost health needs.
Legislative/Executive Process and Procedures
What is the process for repeal of the Affordable Care Act?
A complex legislative process is required to repeal the Affordable Care Act. In the Senate, 60 votes (three-fifths of Senators) are needed to end debate and vote on issues. It is unlikely that 60 Senators would move to vote on the repeal of the Affordable Care Act, and so Congress is proceeding with reconciliation bills which require only a simple majority of 51 votes to pass and are not subject to filibuster.
These reconciliation bills can repeal certain parts of the Affordable Care Act that are related to spending and revenue such as premium assistance, tax measures, and additional funding for states’ Medicaid programs. The budget resolution passed by Congress in mid-January 2017 includes “reconciliation instructions” directing certain congressional committees to produce bills by January 27 that produce a specified amount of savings for the federal budget. The reconciliation bill is expected to give Congress a certain amount of time after it is passed to produce a replacement plan to the Affordable Care Act, though pressure is mounting to produce a simultaneous replacement plan or at least designate protections for those who currently have coverage.
What is the current legislative strategy?
Attention has turned to repealing and replacing the Affordable Care Act rather than just repealing it. Members of Congress and the Administration have heard from people that they need to make sure a health coverage system is in place. On March 6th, the House Energy and Commerce and Ways and Means Committees released legislation, “Budget Reconciliation Legislative Recommendations Relating to Repeal and Replace of the Patient Protection and Affordable Care Act”. These committees are marking-up (reviewing) the legislation on March 8th.
It is anticipated that the legislation will need to pass through several other committees before being voted on by the full House of Representatives. After that, the Senate will consider the legislation.
Q: How would the tax credits in the proposed American Health Care Act compare to the existing premium tax credits provided by the ACA?
A: The ACA provides tax credits based on household income to individuals and families tohelp make the cost of coverage more affordable and complying with the requirement to have health coverage or pay a fine (the individual mandate) easier for moderate and low-income individuals. By applying for coverage through the ACA’s Marketplace (sometimes called Exchanges), people in households with incomes between 100% and 400% of the Federal Poverty Level (FPL) are eligible to receive a tax credit that can be automatically applied to their monthly premium, effectively subsidizing their coverage. The amount of this subsidy varies, based on the individual's income, location, and age.
Recent ACA replacement proposals would eliminate the ACA's premium tax credits for nearly all individual health insurance plans. (There is an exception for “catastrophic plans” which are the least costly because they offer the least amount of coverage.) Instead, the proposed American Health Care Act would provide standardized tax credits based only on an individual's age. These tax credits would not account for an individual's income, which would lead to the neediest low-income individuals not receiving adequate financial assistance to defray the cost of insurance coverage.
The schedule for age-adjusted tax credits in the American Health Care Act are:
under age 0: $2,000
between 30 and 39: $2,500
between 40 and 49: $3,000
between 50 and 59: $3,500
over age 60: $4,000
Resources:
What impact does the President’s recent Executive Order have?
On January 20, President Trump signed an executive order “easing the burden of the Affordable Care Act.” The order essentially instructs heads of all executive departments and agencies to exercise authority and discretion to grant waivers and exemptions on fiscal or regulatory burdens related to the Affordable Care Act. The order was not specific in actions and it is not clear the full impact this might have. Major changes would require legislation or a regulatory public comment period, but there a number of things that could be done through the agency discretion stated in the order. Some think this could strain the individual market by eliminating the individual mandate that requires people to buy health insurance (the mandate brings healthy people into the insurance market to balance the risk, with the goal of making healthcare more affordable). The order also calls for discretion in granting greater flexibility to states in implementing the law.
What about Medicaid?
The American Health Care Act includes proposals to eliminate and phase out Medicaid expansion, as well as place per capita capson Medicaid. The Society opposes these proposals. Under per capital caps, state-run Medicaid programs would receive a fixed amount of federal money, shifting costs to states and likely leading to service or eligibility cuts. Medicaid currently operates as a federal-state match, with each putting in a percentage of costs to operate the Medicaid program. If costs to the program are higher than anticipated, (which has occurred from events such as the opioid crisis, Zika outbreak and breakthrough but exorbitantly priced drugs ) then both the federal and state governments are required to increase their proportional share.
How Do I Get Engaged
What can I do?
If you have experience buying health coverage through an exchange or marketplace, have benefitted from or fallen through a gap in Medicaid expansion or have experience with other provisions of the ACA, please let the Society know. We are always looking for both positive and negative experiences to inform us and advocate for what people with MS need. You can share your story on the “Advocate for Change” page of the Society website or contact .
You can also sign up for the MS Activist Network to receive updates and action alerts, letting you know when to contact your elected officials and urge them to take action to support people with MS. (also on the “Advocate for Change” section of the website).
Or, reach out directly to your elected officials and let them know what you need from affordable, quality health coverage.
If you have questions about your healthcare coverage, contact an MS Navigator at 1-800-344-4867.
Additional Information
How do we transition to quality and value in the healthcare system?
Research investments in comparative effectiveness, health services, quality measurement, alternative payment and care models and the inclusion of patients in these improvement efforts are some examples of the work needed to support the transition to value, quality, and patient-centered approaches in healthcare. The Patient Centered Outcomes Research Institute (PCORI) and the Center for Medicare and Medicaid Innovation (CMMI) are just two of the organizations with government funding that have been exploring value and quality.
The Affordable Care Act committed funding to this important work and a replacement law should retain this commitment. In 2016, PCORI launched four MS-specificresearch projects totaling over $20 to help compare the benefits and risks of the disease modifying therapies.
What is patient-centered care?
Patient-centered care values individual patients’ goals for their own care and enables partnerships between patients and their healthcare providers to determine treatment plans and the methods to achieve them. Patient-centered care is possible when delivery and payment systems are aligned in support of these goals.
What are Interstate Sales of Health Insurance Policies?
Some have advocated for allowing health insurance policies to be sold to a person in any state regardless of where they live. Often referred to as “interstate sales” or “buying across state lines”, this approach would allow insurers to be licensed and regulated in just one state but still sell insurance in others. Proponents of interstate sales believe individuals would choose less expensive health insurance sold in other states if it was available to them, and the additional competition between insurers that would result could help lower premiums for everyone.
Many people may be surprised to learn that the Affordable Care Act includes a provision allowing for interstate sales (Sec. 1333) to encourage healthy competition between insurers, and that numerous states have explored the possibility. Several states enacted their own state laws to further encourage interstate sales, but to date, no insurer has chosen to offer any. Other concerns about interstate sales include their potential negative effect on people with chronic, complex needs who could lose out on important benefits and patient protections in exchange for lower-priced coverage. Others cite the possible long-term effect of interstate sales as destructive to the overall viability of the individual insurance market if younger and healthier people abandon more costly policies, leaving older and sicker people in the plans providing more comprehensive and expensive coverage. This scenario is the reason the professional association of insurance commissioners considers interstate sales “a race to the bottom”.
Resources:
‘Interstate Health Insurance Sales: ‘Myth vs. Reality’, The National Association of Insurance Commissioners