1. Federal Legislation: Implications for State Reforms August 2006 State Coverage Initiatives Mila Kofman, J.D., Associate Professor Health Policy Institute, Georgetown University 202-784-4580 direct; 202-687-0880 main mk262@georgetown.eduwww.healthinsuranceinfo.net

2. S. 1955 Health Insurance Marketplace Modernization and Affordability Act (Sen. Enzi) – manager’s amendment May 2006 S. 1955 Health Insurance Marketplace Modernization and Affordability Act (Sen. Enzi) – manager’s amendment May 2006 H.R. 2355 Health Care Choice Act (Rep. Shadegg) H.R. 2355 Health Care Choice Act (Rep. Shadegg)

3. S.1955: amends ERISA & the Public Health Service Act (PHSA) Title I (ERISA): small business health plans (a.k.a. AHPs) Title II (PHSA): health insurance premiums for small businesses health insurance premiums for small businesses mandate-free individual and group health insurance mandate-free individual and group health insurance Title III (PHSA): regulation of insurance companies A fundamental change in how health insurance policies and companies are regulated in the United States

4. Title I: AHPs Fraud: self-reporting and deeming (90 days deemed certified): Fraud: self-reporting and deeming (90 days deemed certified): Crooks don’t report to the feds that they are lying, cheating, and stealing –DOL (1/300 years audits), 2001-2003 144 scams (3 DOL, 41 states), $252 million claims (200,000 policyholders); #1 way to sell is through associations; MEWA registration problems; a problem since 1974 Cherry picking (product design, marketing, and rates): Cherry picking (product design, marketing, and rates): –Each business underwritten –Dumping bad risk Adverse impact on regulated market Adverse impact on regulated market

5. Title II rating for small group market SBHPs separate rating class (rates not tied to small group rates) SBHPs separate rating class (rates not tied to small group rates) –Association: rate variations among employers at least 5:1 Small group: Small group: –Adopting states: at least 5:1 (states may allow broader variations) »3:1 for age, health, or both …insurer’s choice »other rating factors: industry, group size, geography, participation rate, class of business, wellness programs »Renewal: same (may increase 500%+ if claims are high) –Non adopting states: unclear (“plan” can’t vary by more than 500%, “plan” undefined…each insurer chooses between new federal standard (not required to follow federal standard) or existing state law »Renewal: trend + 15% for claims

6. Two products: 1. Mandate free product –exempt from state benefit mandates –Broad: benefit requirements, provider requirements, special population protections 2. Product available to state employees in CA, FL, TX, NY, and IL (insurer’s choice) HDHPs HDHPs No requirement on cost-sharing/affordability No requirement on cost-sharing/affordability Title II: individual, small group, large group health insurance (including SBHPs/AHPs)

7. Title III: restrictions on oversight and other provisions Restrictions on state oversight authority over insurance companies (rate/form filings and market conduct) Restrictions on state oversight authority over insurance companies (rate/form filings and market conduct) Unprecedented deregulation of industry: NO oversight of new federal standards: Unprecedented deregulation of industry: NO oversight of new federal standards: –No federal authority –Adopting states: federal courts exclusive right to interpret (insurers challenge states in federal court) –Non-adopting states: insurers sue states in federal court (expedited review federal court of appeals) »This could bankrupt states »Unusual: congress allow regulated industry to sue state regulator in federal court on expedited review –No private right to sue in federal court to enforce standards

8. S. 1955: A fundamental shift in the way health insurance is regulated in the United States Preempts existing state-based regulation that protects consumers of insurance (loss of rights in every state)…creates a federal “ceiling” Preempts existing state-based regulation that protects consumers of insurance (loss of rights in every state)…creates a federal “ceiling” Restricts state oversight authority of insurance companies Restricts state oversight authority of insurance companies Creates an unregulated insurance industry: relies on self-regulation Creates an unregulated insurance industry: relies on self-regulation Opens the door to fraud and abuse Opens the door to fraud and abuse

9. To-date: To-date: –Letters from insurance departments –Attorneys Generals (41 signed) –Governors –State Legislators: NCOIL Groups: consumer groups (e.g., Consumers Union, AARP, Families USA, National Partnership for Women and Families, etc), patient groups (American Cancer Society, American Diabetes Association), labor unions (AFL/CIO), doctors (AMA, APS, APA), nurses and other health care providers, small businesses (Small Business Majority), some insurance companies, etc. Groups: consumer groups (e.g., Consumers Union, AARP, Families USA, National Partnership for Women and Families, etc), patient groups (American Cancer Society, American Diabetes Association), labor unions (AFL/CIO), doctors (AMA, APS, APA), nurses and other health care providers, small businesses (Small Business Majority), some insurance companies, etc.

10. H.R. 2355 Licensed in one state (“primary” state) and do business in all states exempt from state laws (don’t have to do business in primary state) Licensed in one state (“primary” state) and do business in all states exempt from state laws (don’t have to do business in primary state) Primary state: RBC + optional external review Primary state: RBC + optional external review Restrictions: Restrictions: –Solvency –Unfair claims settlement –Fraud and abuse –Market conduct –Forms and rates

11. Individual Health Insurance Products Primary state’s laws apply: Primary state’s laws apply: –Access (if any) –Mandates –Rating (if any) –Other: external review, marketing standards and practices, network adequacy, disclosure, etc. secondary state’s laws and authority: limited and restricted secondary state’s laws and authority: limited and restricted

12. State jurisdictional and financial issues State jurisdictional and financial issues –Must expand authority of DOI to enforce laws extraterritorially –Resources: funding for DOI to enforce nationally (even if no in-state consumers are affected) CBO: CBO: –Estimates 1 million people will lose job coverage as healthy people drop it (and employers drop coverage) –Medicaid spending would increase by $1 billion (2007- 2015) in part as a result of lost job coverage among low-wage workers

13. Public policy… Private health insurance: finance medical care and financial security Private health insurance: finance medical care and financial security goals: make health insurance more accessible and more secure, and ensure adequacy goals: make health insurance more accessible and more secure, and ensure adequacy S. 1955 and H.R. 2355: S. 1955 and H.R. 2355: –not accomplish goals –destabilize already fragile insurance markets (risk segmentation; cost-shifting) –hurt vulnerable populations –undermine new state reforms (that rely on private insurers taking on risk)