1332 juiced up

Margot Sanger-Katz from the NY Times flags an interesting pre King vs. Burwell Republican plan that is actually interesting in a non-sarcastic manner.

Let’s look at it with the 53 page PDF here:

Section 101 is the three options a state has if the Supreme Court ruled in favor of the fabulist argument advanced in King. Option 1 would be to stay under PPACA and establish a state based exchange. Option 2 would be a complete withdrawal from PPACA with no subsidies. Option 3 would be to establish a HSA like equivilent of coverage with most of the regulator requirements, taxes and mandates of PPACA thrown out. This is actually interesting if the funding makes sense. The default assumption is a complete opt-out. States would have to to opt into either Option 1 or Option 3.

Section 102 talks about the state alternative with HSA. It wipes out mandates and federal regulation. Essential health benefits, minimal actuarial value coverage and other regulatory requirements of PPACA that define a qualified health plan also are junked in this section. 102-4-A authorizes an initial HSA grant and the rest of 102-4 describes the mechanics of that grant. 102-C establishes a public health block grant that is 2% of the eligible funds for the HSA.

Section 103 determines the size of the HSA subsidy. This is where the money matters. The HSA amount is age and geography adjusted which is very similar in function as the ACA benchmark Silver is determined by zip code and age of the recipient. Bingo — 103-1-B is good news.

—The amount speci-
14 fied in this subparagraph for a State for a year
15 is 95 percent of the Secretary’s estimate of the
16 total payments that would have been made (as-
17 suming the existence of a State established Ex-
18 change in the State) under section 36B of the
19 Internal Revenue Code of 1986 and under sec-
20 tion 1402 of PPACA with respect to all quali-
21 fied residents in the State in the year

This is effectively the Basic Health Plan (Section 1331) funding mechanism. If anything it could be more generous depending on rule making and technocratic judgement as it is 95% of the total expenditure for all qualified residents in the state instead of the current rule making guidance that a 1332 (State Innovation Waiver) has to be budget neutral with regards to actual enrollment. This is fascinating!

103-2 is even more interesting. It is a block grant for states that did not expand Medicaid. The funding for 103-2-b is 103-1-B plus

the Secretary’s estimate of the
2 total payments that would have been made
3 to the State under title XIX of the Social
4 Security Act for individuals eligible to be
5 covered under section
6 1902(a)(10)(A)(i)(VIII) of the Social Secu-
7 rity Act assuming the election of a State to
8 provide Medicaid coverage under such sec-
9 tion and assuming the applicable Federal
10 medical assistance percentage were 95 per-
11 cent with respect to such individuals.

I can read this two ways.  The first is that this would be 95% of whatever the Expansion state match would be (100% 2014-2016, 95% 2017, 90% by 2020 etc) or just a 95% match.  I’m not sure how to read it.  The 95% federal match is a richer long term match than the Expansion states that would have to assume a 90% long term match for their Medicaid eligible population.

The rest of 102 deals with Medicaid wrap-around and ESI buy-up supports in a reasonably and consistent manner. 103-c-2-d is slightly problematic as there is no adjustment for Medicaid payments based on sex even though we have good evidence that female Medicaid beneficiaries cost slightly more. If 103-B-2 works correctly this should wash out but it would have been an implementation concern.

Section 104 deals with Exchanges. States may do what they want with the Exchanges in whatever manner they want. Healthcare.gov is to be made available as a resource to the states.

Section 104-C is also interesting. This is the coercive participation mechanism that replaces the individual mandate. States may enroll qualified/eligible individuals into creditable coverage as a default option. Everyone gets enrolled into something. The default coverage is paid for by the subsidy that an individual is eligible for and no out of pocket premium. As a practical matter, the coverage will have a very low actuarial value (105-2)and it will be truly be hit by a meteor coverage but it forces young and healthy people into the risk pool. This works because 103-1-B funds the state on all qualified individuals. The money pool may be bigger than current paid out APTC+CSR outlays.

104-D-1 has risk corridors and re-insurance that is funded locally. 104-d-2 is a risk adjustment change. The risk adjustment would be much closer to Medicare Advantage widget payments instead of the current concurrent revenue neutral comparative risk score times total premium zero-sum transfers. Widget payment risk adjustment is easier to predict and implement but not as useful.

Section 105 has meat in 105-D. This is the other coercive participation mechanism. If an individual does not elect to have creditable coverage and opts out of the auto-enrolled low value coverage for more than a 63 day break (the current HIPAA break), they are subject to underwriting exclusions and or uprated premiums for two years along with a 10% late enrollment premium penalty for the following eighteen months.

Section 106 deals with federal benefit regulations. The Option 3 HSA states would have to keep no lifetime or annual limits as well allow Under-26 coverage through employer sponsored insurance. Everything else in PPACA Title 1 goes out the window.

This actually seems to me to be a reasonable enough structure of a replacement plan. It allows states that want to keep PPACA to keep PPACA. It allows states that want to go in a different direction to go in a different direction with a super 1332 State Innovation Waiver and the possibility of higher net levels of federal funding depending on CMS rule making. The great weakness is that it allows states to screw their citizens over by opting out completely. But Option 3 (the HSA route) has a modified three legged stool approach. It has community rating, it has subsidies and it has guaranteed issue. All of it is a twist on the current ACA three legged stool but they descend from the same family tree with more than a passing resemblance.

Subtitle B is the Medicaid section.

Sec.111 shields HSA assets from any Medicaid asset test. This makes the HSA a much more attractive route for low income individuals. It specifically excludes this exclusion from long term care. An HSA will be drained to pay for a nursing home before Medicaid becomes the payer of last resort. It is not a complete tax give-away.

Subtitle C is Price Transparency

Section 121-A creates a national standard for emergency services out of network charges. It would be 85% UCR for professional services or 110% of Medicare for facility and technical services. That would be a massive improvement in terms for most if not all states.

Title 2 is Health Savings Account/Tax law. I am not a lawyer. I am especially not a tax lawyer. Most of this needs a tax lawyer to work through. An HSA could be used to pay the premiums of a plan described as Option 3 in Title 1.

Section 204 — cash prices need to be published by providers for their services before rendering a service. I don’t think this would do much as price disclosure has not had much of an impact as there is still quite a bit of uncertainty and expensive to acquire and interpret information in the medical market. I don’t think it hurts. I don’t know if it helps much.

Section 212 tells the IRS and Treasury how to administer the HSA credits described in Title 1

Overall, this plan makes a good deal of sense. It is effectively a Super 1332/1115/1331 on steroids with what seems to me at first glance to be adequate funding and a coherent coercive mechanism to get healthy and young people into the market. If this or something like this is the “Replace” option, it would and should easily get 70 votes in the Senate as it is effectively a rebranding of the ACA with slight conservative tweaks on it.

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59 replies
  1. 1
    PaulW says:

    So in short, we can keep calling it Obamacare just to spite the GOP. got it.

  2. 2
    Baud says:

    what seems to me at first glance to be adequate funding

    Not sure why given the many local funding requirements.

  3. 3
    Michael says:

    I’ve never really understood the Affordable Care Act. Because I’ve never had to, honestly – I’ve always had good insurance through work. Other than the big stuff, like keeping kids on insurance till 26, no pre-existing condition denials, and stuff that makes the news, I know little about it.

    Other than “Medicare for all,” which I would prefer, being originally from a country that basically has this and understands how well it works, I’ve always wondered what people who defend Obamacare (and can talk more intelligently about the details than me) would change about it if they could tweak it and make it better.

  4. 4
    low-tech cyclist says:

    So any chance that any Republicans have this in mind now?

  5. 5
    rumpole says:

    Here’s what I don’t understand. Health care costs x, so you need to make, say, x +5 to have things like a roof and food. You’re going into an environ where automation is likely to displace a number of people’s jobs. So unless the government funds these HSAs, where does the money come from? I’m thinking specifically of those folks who are in the gap now–forced to buy insurance but too rich for state medicaid.

  6. 6
    Michael says:

    @PaulW: That would be really funny.

  7. 7
    Baud says:

    And where would federal funding come from since they want to eliminate all of the ACA taxes.

  8. 8
    dm says:

    @PaulW: not until after it passes and the President signs it. Then we can go back to calling it Obamacare.

  9. 9

    @Baud: The funding is all federal and if you squint at the language right, the Option 3 funding could be richer than PPACA as is funding.

  10. 10
    Baud says:

    The default coverage is paid for by the subsidy that an individual is eligible for and no out of pocket premium.
    …..
    If an individual does not elect to have creditable coverage and opts out of the auto-enrolled low value coverage for more than a 63 day break (the current HIPAA break), they are subject to underwriting exclusions and or uprated premiums for two years along with a 10% late enrollment premium penalty for the following eighteen months.

    If the premium is 100% paid, why would anyone not sign up for the crappy policy just to have it?

  11. 11
    Baud says:

    @Richard Mayhew:

    Except this:

    104-D-1 has risk corridors and re-insurance that is funded locally.

    Doesn’t this plan benefit blue states who care about their citizens’ health? No way it passes the current Congress.

  12. 12
    NotMax says:

    More damn flavors than Baskin-Robbins.

  13. 13

    @Baud:
    But that funding comes out of the general federal grant. This is basically how Medicaid risk adjustment works financially but uses Medicare Advantage mechanics.

  14. 14
    OzarkHillbilly says:

    @Baud: C’mon… You should know by now that deficits don’t matter (if a republican is in office)

  15. 15
  16. 16
    Baud says:

    @OzarkHillbilly: Very few things seem to matter if a Republican is in office.

  17. 17
    Central Planning says:

    @Baud: How dare you make me sign up for free healthcare! Just another liberal government over-reach.

  18. 18
    OzarkHillbilly says:

    @Baud: Tax cuts for the rich sure do.

  19. 19
    Villago Delenda Est says:

    Won’t work, because the bottom line is the GOP wants people to suffer.

  20. 20
    Aleta says:

    Thanks for the details and the discussion.

  21. 21
    rikyrah says:

    Thanks for the information, Mayhew

  22. 22

    @Baud: Freedumb? Given that it is an opt-out I think very few people would actually opt-out. The ACA on both the Exchanges and Medicaid Expansion are Opt-in programs so that creates a barrier to utilization. Opt-outs are easier to capture a wider proportion of the population as we can count on low effort capture instead of chasing reluctant outsiders.

  23. 23
    ThresherK says:

    My kneejerk reaction translates

    Devolves individual markets to states

    as

    Let’s see how Texas screws this up.

  24. 24

    @ThresherK: Given that Texas has already screwed things up under PPACA as rewritten by Sovereign Dignitude of the States Roberts by throwing their most vulnerable non-covered pre-PPACA population under the bus by refusing Medicaid expansion, they can’t screw it up much worse. If anything they have to take the money that is partially determined by the Medicaid Expansion eligible population and do something with it. It might not be better, but it is hard to be worse (and yes, I know I am inviting a “hold my beer” moment there)

  25. 25
    bemused senior says:

    @Michael: I think the problem with Medicare for all is the scope it gives Congress to fuck with reproductive health care. Not a problem for people of Medicare age, but a huge target for younger populations.

  26. 26
    raven says:

    How would this address all the whining about “you said I cold keep my doctor” or is that all over?

  27. 27
    WereBear says:

    @Villago Delenda Est: Won’t work, because the bottom line is the GOP wants people to suffer.

    Yes, though that’s a side benefit. What we have is people seen as an excess resource who don’t pay for themselves because their labor is stolen.

  28. 28
    Exurban Mom says:

    You are such a resource, Richard Mayhew. I can’t say enough how I appreciate being able to turn to your posts here to understand this stuff. It’s absolutely excellent and so helpful. Thank you.

  29. 29
    ThresherK says:

    @Richard Mayhew: Just as I thought (i.e. feared). Thanks for being on top of things anyway. Too much empathy in me to just laugh at every single Texan who’ll get further screwed on this.

  30. 30
    Yarrow says:

    @raven:

    How would this address all the whining about “you said I cold keep my doctor” or is that all over?

    I think the current concerns are, “I won’t be able to go to any doctors” and “I won’t have any health insurance at all.” So maybe the “keep my doctor” thing has taken a back seat?

  31. 31
    Sam Dobermann says:

    @ RichARD Mayhew link to document doesn’t work. Yes I actually want tp read it.

    Question re funding: Are they taking away the tax benefits for employee insurance? Do they give minimal insurance and if the Boss wants to do more for his employees and that cost counts as income to the employee then said workers’ benefits will be taxed which insures extra payroll and income taxes. This can hurt all especially income less than SS maximum.

    There is more to say but I am to sleepy. Am on a weird schedule. I will, finally, work up a “what the ACA does. Did you know it includes loan repay for primary care doc s and others in the primary care area.
    night folks

  32. 32
    Sam Dobermann says:

    @bemused senior: Absolutely.
    No Abortions for sure even for rape … by some of them.

    They can tinker with this — every year or every other year. In England Conservative Gov is starving Health Service. One reason Brexit passed was cause the Brexeters promised that all the money they saved would go to the NHS. It won’t.

  33. 33
    sam says:

    @Michael: I can probably explain the political reality of why we ended up with something like this hybrid bastardization known as the ACA rather than a single-payer/medicare for all system (which I would have personally preferred).

    Everyone loves to cast the insurance industry as villains, largely with good reason, and a single payer system would have overthrown the entire infrastructure. A lot of us would have, in an ideal world, really enjoyed that. Also, if we were starting from scratch where there were no existing insurance company infrastructure, we probably wouldn’t design something that looks like what we have today (or what we had 10 years ago).

    But the reality is, despite its worst impulses, the insurance industry exists, and for all of its systemic problems, it also comprises a significant portion of our economy. And it employs a lot of people. In EVERY state (because insurance is regulated at the state level). So no politician, not even the most liberal of liberals, when push comes to shove, was going to create a system that could get enough votes to get out of committee, much less survive a filibuster, that wiped out the insurance industry in its entirety.

    Obama is a smart guy, and he saw this up front, so he and his team basically tried to design a system that superimposed an “insurance for all” framework that *used* the existing insurance companies – and they tried to balance the various interests – the extremely poor would get medicaid, because they couldn’t afford any private insurance, the insurance companies would get a massive influx of new customers (who would get helped by subsidies), but in exchange they had a host of new limits on what they could charge, who they could refuse to cover, etc.

    The ACA is a frankenstein’s monster in many ways. but there *is* a logic behind why it is the way it is.

    (There were supposed to be other pieces (public option, the ability to buy in to medicare early), but they were killed by various assholes like Lieberman.)

  34. 34
    GregB says:

    After seeing her brilliant performance I think that we should make Betsy DeVos Czar of All of Things.

    Her brilliance will be able to fix this silly healthcare thingy along with the great work she’ll do turning free and public education into a simple program that will train the citizens to be compliant low-wage servants. I bet she is good enough voucherize this and the healthcare and education systems and offer Carl’s Jr. coupons to boot.

  35. 35

    @ThresherK:

    Too much empathy in me to just laugh at every single Texan who’ll get further screwed on this.

    You’re a better man than I. I hope the poor, wretched, and sick who voted for Trump die before the rest of us.

  36. 36
    dexwood says:

    @GregB:

    Let’s not forget her unwavering, patriotic stand against the grizzly bear menace facing our innocent children.

  37. 37

    @Sam Dobermann: Try this link –http://www.cassidy.senate.gov/imo/media/doc/Patient_Freedom_Act_Legislation.pdf

    Updated in the post

  38. 38
    Another Scott says:

    All this stuff is outside my bailiwick, but when I see “block grants” my spidey sense starts tingling.

    Isn’t it the case that “block grants” usually (especially these days) end up being spent on other things than what’s “intended” by the federal legislation? It’s not the same, but look at the tobacco settlement. Billions went to the states as part of the settlement, with the nominal expectation that it would be used for education, smoking cessation programs, and the like, but AFAIK, it just got dumped into the general fund in many/most places and thus made it even easier for Brownbackistan to cut taxes.

    National programs should have national standards and be paid for by national funding. Sure, “laboratories of Democracy” and all that, but until the GOP can show that their glorious “block grants” aren’t Trojan Horses to slowly strangle programs, I’m not on board.

    My $0.02.

    Cheers,
    Scott.

  39. 39
    Another Scott says:

    @dexwood: Diane Ravitch was on “1A” (the replacement for the Diane Rehm Show) on NPR this morning. She gave it to DeVos with both barrels.

    It was glorious. :-)

    Cheers,
    Scott.

  40. 40

    @Another Scott: I think Medicaid grants are already used on weird pet programs and crony handouts, so I’d expect that but on steroids.

  41. 41
    artem1s says:

    I get the underlying concept of ACA to bring more people into the pool and even out the costs. I get the limits on private insurance companies; the 85% mandate, to me, seemed to be one of the most important aspects; a minimum of premiums that had to go back into actual care (not golden parachutes for directors); I get benefits vs. costs and why vouchers are granny starvers, thanks to Mr. Mayhew’s writing here on this blog.

    what I don’t understand is how allowing insurance companies selling across state lines will affect the market. It seems this is a thing that the austerity assholes are continually pushing, so I suspect it will be bad for customers. But I would like to understand what this push is about, and how that would affect states that opt to set up their own version of ACA (which seems likely given the do-nothing administration coming into power). Might customers have the option to deal with insurance companies in states that form their own version of ACA? I’m thinking CA and NY specifically. Maybe MA, since they have the longest history with an ACA style system. Also, since the federal funding comes from payrolls at the state level, how will defunding federal ACA affect the state’s obligation to send that money into the swamp? I guess I’m curious about how some of this state level policy stuff might play out and how the Dems can leverage the message of protecting their constituents from the new robber barons in DC. I know it’s not fair to red state Dems but if it’s happening anyway, why not use it to get those voting blocks back or at least seriously questioning what the GOP is doing to them.

  42. 42
    dexwood says:

    @Another Scott:
    Thanks, will give it a listen when it comes on later here.

  43. 43
    catclub says:

    @Baud:

    And where would federal funding come from since they want to eliminate all of the ACA taxes.

    This, This, This.

    The first and only priority is to eliminate the taxes on the very rich, all the rest is ephemeral to the GOP. That elimination is fully within the reconciliation process, and will happen.

  44. 44
    WereBear says:

    @artem1s: If heath insurance is not subject to the laws of each state, they will buy a low population state, gut the regs, and sell all their crap from there.

    North Dakota for credit cards, Delaware for shell corporations, etc.

  45. 45
    catclub says:

    @Sam Dobermann:

    Question re funding: Are they taking away the tax benefits for employee insurance?

    I think the tax on cadillac employee health insurance plans has not yet come to be applied, but is coming – maybe in 2018. It will be hated by powerful people – the kind who get cadillac health plans.

  46. 46
    Another Scott says:

    @artem1s:

    what I don’t understand is how allowing insurance companies selling across state lines will affect the market. It seems this is a thing that the austerity assholes are continually pushing, so I suspect it will be bad for customers.

    It’s a race-to-the-bottom thing. Richard had a post about one variation a few days ago. IIRC, basically, it’s a way to gut rules about what a minimum policy has to provide and other protections. A policy that may be fine for a farmer in ND may be completely inadequate for someone in East LA, but as long as the policy meets the letter of the inadequate law then California couldn’t enforce the higher standard.

    Richard has posted lots and lots of details about things like this – check the Quick Links thingy at the top of the (desktop version) page, then click “Mayhew on Insurance”.

    HTH.

    Cheers,
    Scott.

  47. 47

    @WereBear: you’ll also see the concomitant fucking-up of the government of that state itself by single-industry regulatory capture.

  48. 48
    Vhh says:

    Now that Putin’s Russia is Trump’s model (bigly), maybe we should look at their universal health coverage. From Wikipedia (copy):

    The Constitution of the Russian Federation has provided all citizens the right to free healthcare under Mandatory Medical Insurance since 1996. In 2008, 621,000 doctors and 1.3 million nurses were employed in Russian healthcare. The number of doctors per 10,000 people was 43.8, but only 12.1 in rural areas. The number of general practitioners as a share of the total number of doctors was 1.26 percent. There are about 9.3 beds per thousand population—nearly double the OECD average.

    Expenditure on healthcare was 6.5% of Gross Domestic Product, US$957 per person in 2013. About 48% comes from government sources. About 5% of the population, mostly in major cities, have health insurance.

  49. 49
    🌷 Martin says:

    Where would this leave a state that wanted to go the single payer route? In order to pull that off, the state would need to either turn off the spigot of health related tax revenues to the feds or get that money back in grants. This proposal doesn’t seem to provide for either.

  50. 50
    sam says:

    @artem1s: to give a more specific example, Pre-ACA, New York already had a rule barring insurers from banning people who had pre-existing conditions. The downside, of course, is that it made non-employer based coverage pretty expensive, so the people who bought it were those that really needed insurance (you want a vicious cycle – it’s exactly this “only the sickest” situation that the mandate was addressing). But the law was a lifesaver for at least one friend of mine, who prior to its passage, stayed in a job she detested for over a decade because she couldn’t lose her insurance (she’s the same friend who has Crohns disease that I posted about the other day). The law essentially allowed her to go to law school (we met in our first legal job together).

    If insurance companies could sell across state lines, insurance companies in, say, Nevada (home of the no-regulation credit cards) could sell into New York without having to meet New York’s rules. so Nevada companies could come in with a bunch of low-cost, low-coverage plans, which might be appealing to a lot of relatively healthy people who are paying more attention to the price than to the consequences. These plans will bar pre-existing conditions. These plans will have lifetime limits. It won’t matter if New York has a slate of rules saying otherwise. And the price competition will drive the NY insurers out of business, leaving New Yorkers with no options *except* these terrible, low-coverage plans.

    This is what the boilerplate “selling across state lines” means in practice.

  51. 51
    🌷 Martin says:

    @sam: It’s important to recognize that there is no prohibition against selling across state lines nor was there prior to ACA. The only thing stopping companies from doing it is market dynamics. Sure, regulatory complications dealing with another state is part of that, but even more is the fact that most states have local monopolies that are near impossible to breach unless you are a national insurer signing up group policies for large companies. If you are BCBS of State A and want to enter state B, you’re likely going to go up against the local monopoly of BCBS of State B, which already has contracts with every hospital and doctor group, every pharmacy, etc. You’re going to need to build up all of those contracts while only being able to grab a minority of that market (because you don’t yet have the contracts). You either take a big risk and go all-in against that entrenched agent investing as if you already benefit from network effects trusting that they’ll materialize, or you take the cheaper route and just merge with that other monopoly.

    The reason why market dynamics don’t work the way that republicans want is because this isn’t a free market, in several respects. Consumers can’t opt out of the market if their employer has a contract with that insurer. Consumers can’t afford to go out of network to give market power to care providers. Insurers can’t exit the market because in many cases, there would be no market left, which incentivizes states to cater to those monopolies only strengthening them.

    So trying to move to free market principles now, after any semblance of a free market has long vanished, is just an exercise in failure. They can’t get that market back without some massive changes to how the markets work, and they aren’t able to deliver that. You have seen that happen in some other industries due to the internet which has been able to eliminate distribution costs and transaction costs, and enable a different scale of aggregation (Amazon, for example) but some of that can never apply to health care, and some of that we are not yet equipped to apply (moving prescription and fulfillment online, for example). Republicans don’t know enough economics and business model theory to understand any of this.

  52. 52

    I’m not parsing the phrasing “HSA like equivilent of coverage” – I read it as “health savings account like equivalent of coverage” but that *still* doesn’t quite parse for me in context.

    HSA plans at the state level?

  53. 53
    J R in WV says:

    @Vhh:

    The numbers on Russia’s health care capabilities are interesting, but need other numbers from Europe, Canada and America for comparison.

    If whatever changes to national health care programs are made do not include 1) ban on pre-existing condition issues, 2) ban on life-time caps for chronic or catastrophic illnesses or injuries, 3) at least 85% of premiums reinvested in health care for payees (I don’t know why this shouldn’t be closer to 95% they should be getting used to paying for their own hookers and blow now), 4) all the other requirements intended to improve private insurance that “Richard” knows about and has published but which I don’t understand and/or remember now, it will be a failure. And they will attempt to call it Obamacare, especially as failure becomes obvious.

  54. 54
    artem1s says:

    @sam:
    @🌷 Martin:
    thanks for all the responses. I suspected that it was to work around state level regs.

    I guess I’m hoping progressive state lawmakers and think tanks will be working on creative new ways to enforce local regs or at least ‘tariff’ the hell out of out-of-state providers who don’t meet minimum standards. In other words, use all the ‘free market’ and ‘states rights’ BS against these assholes. They may go down in flames when Roberts gets his hands on it, but there is always the law of unintended consequences.

  55. 55

    @🌷 Martin: It would be Option 1 (standard PPACA) with a standalone 1332 waiver for single payer.

  56. 56
    sam says:

    @🌷 Martin: right, but “selling across state lines” now involves complying with each state’s regulations and submitting yourself to the jurisdiction of the state insurance regulator. We have to remember that “selling across state lines” is not actually about “selling across state lines”. It’s just GOP code for “dismantling any and all state regulations, (not all,but) many of which were designed to protect the residents of those states”.

  57. 57

    @sam: Right — my former employer (UPMC Health Plan) has a home base in Pittsburgh and sells overwhelmingly in Pennsylvania. When it sells in Pennsylvania, it is regulated by the Pennsylvania Insurance Department or the Department of Human Services.

    It also has sold at various points Medicare Advantage plans in West Virginia and Ohio. When they were selling there, those plans were regulated in either Columbus or Charleston. And that meant the internal plumbing to pay claims was slightly different for an Ohio plan than a Pennsylvania plan. All the operations were coming out of one (or two) buildings in Pittsburgh but the regulatory requirements and reporting requirements as well as recipients were different.

  58. 58
    PhoenixRising says:

    HSA will be drained to pay for a nursing home before Medicaid becomes the payer of last resort.

    I would like to meet this person who has leftover money in the HSA account, unused after being set aside pre-tax, who is unable to live independently. That would make an interesting interview.

  59. 59

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