2019 Agenda for Improving Health Care Coverage, Equity, and Value in the States

State legislative sessions in 2019 bring new opportunities to advance policy that improves health care coverage, value, and equity. With new governors in 17 states, and hundreds of freshman lawmakers, 2019 also brings opportunities for states and advocates to improve health care and health overall through legislative action.

This advocacy agenda offers options for improving health and health care at the state level during the 2019 session. Bills passed and considered in the 2018 session provide a foundation for health care policymaking in 2019, but there are also new frontiers to explore for health care coverage, equity, and value this year. Here we provide state policy options to consider in 2019 regarding private insurance coverage, Medicaid, oral health coverage, health equity, prescription drugs, surprise medical bills, and health care value.

Improving Private Insurance Coverage

Efforts to undermine the framework of private health insurance have threatened access to and the affordability of coverage, but states have an opportunity to establish protections that will cover more uninsured people and keep premiums down. Legislative options to improve and expand coverage are spelled out in the Families USA report, Seven State Options to Reduce the Number of Uninsured (and Stabilize Insurance Markets). 

In addition to the topics discussed here, this report addresses 1) Medicaid buy-in, 2) state-funded premium and cost-sharing assistance, 3) the Basic Health Program 4) outreach and enrollment assistance, and 5) streamlining enrollment.

Below we provide examples of legislative initiatives that states can pursue to protect and improve their insurance markets in 2019.

State-based individual mandate. 

Starting in 2019, the federal government is no longer enforcing the requirement that all individuals have insurance coverage if they can afford it. States may want to consider implementing their own individual mandates to keep their insurance markets robust and help keep insurance risk pools balanced and premiums reasonable. States may also want to explore policies they can implement that connect efforts to increase enrollment and distribute subsides to income-eligible individuals with the enactment of an individual mandate. States can consider the following examples for exploring a state-based individual mandate:

New Jersey and Vermont enacted state-level individual mandates in 2018 based on the model of the individual mandate included in the Affordable Care Act (ACA).

The District of Columbia enacted an individual mandate under which revenue from the mandate penalty will support outreach to uninsured District residents, dissemination of information to residents about their health insurance options, and other initiatives to increase insurance availability and affordability.

Maryland is considering implementing a state-based mandate combined with a mechanism to use penalty payments collected from individuals who do not have coverage to assist them in directly paying premiums and purchasing health insurance. For more on this model, see Health Insurance Down Payments: The Maryland Plan, from Families USA.

Reinsurance. 

Many states have worked to establish reinsurance programs to lower insurance premiums for consumers who do not receive income-based premium credits. To help advocates and policymakers decide whether this policy is the best use of state resources, Families USA is developing resources on considerations for states seeking to make premiums more affordable. This information will be available in the coming months. Under reinsurance, the costs of very high claims are paid from a pool financed by a wider set of insurers instead of only one insurer, bringing down individual insurance premiums and stabilizing the marketplace. States can pass laws to set up reinsurance programs through 1332 waivers that they can apply to receive from the federal government.

Advocates considering this approach should be aware that 1332 waivers can also be used for harm, and they should consider how to maximize federal resources under a waiver both for beneficiaries of reinsurance (who earn too much to qualify for premium credits) and people who are eligible for income-based premium credits. Information on states that have established or are working to establish reinsurance programs with 1332 waivers is provided through:

Families USA’s 1332 Waiver Strategy Center. Visit our Waiver Strategy Center to learn about approved and pending reinsurance proposals in states including Alaska, Maine, Maryland, Minnesota, New Jersey, Oregon, and Wisconsin.

Alaska’s Reinsurance 1332 Waiver: An Approach that Can Work. This factsheet details how Alaska’s reinsurance system works, and the steps required to obtain a 1332 reinsurance waiver.

Protecting against the harms of short-term and association health plans. 

States have authority to regulate or prohibit the sale of health plans that are not guaranteed to comply with all standards for comprehensive health coverage. Federal regulations have expanded the sale of short-term plans and association health plans, but states may want to enact policies that limit or prohibit the sale of these plans so consumers do not suffer from inadequate coverage or high costs if they enroll in them, and so these plans do not undermine states’ markets for comprehensive coverage. The following resources discuss how states can take action related to short-term and association health plans to protect consumers:

State Strategies to Prevent the Harmful Impact of Short-Term Health Plans. This Families USA resource provides a set of strategies that can protect against short-term plans at the state level.

State Regulation of Coverage Options Outside of the Affordable Care Act: Limiting the Risk to the Individual Market. This Commonwealth Fund study explores how states regulate coverage arrangements that do not comply with the ACA’s individual market and includes recommendations for how states can level the playing field. 

Upholding consumer protections. 

Consumers are guaranteed certain health insurance protections under federal law, but in 2019 states may want to consider enacting these protections under state law if they have not already done so. This will be important to ensure consumers do not lose their current access to coverage or care if federal law changes in the future. Protections that states may want to enact into state law in 2019, if they have not already done so, include the following:

Protections against preexisting condition discrimination. 

States may want to pass laws that mirror current federal law in requiring that medical underwriting is prohibited, such that insurers may not deny coverage, increase premiums, or refuse to cover certain services because of preexisting conditions. To find out whether your state already has preexisting condition protections, see Lawsuit Threatens Affordable Care Act Preexisting Condition Protections But Impact Will Depend on Where You Live.

Coverage of essential health benefits. To ensure consumers have guaranteed access to the 10 essential health benefits currently required under federal law, states can enact essential health benefits requirements into state law. See Connecticut H.B. 5210, passed in 2018, which mandates insurers to cover essential health benefits while simultaneously expanding mandated health benefits for women, children, and adolescents.

Medicaid

Medicaid expansion and protection of Medicaid benefits will remain on the agenda in many states. Although the federal government funds 90 percent of the costs to provide coverage for low-income adults and families, 14 states still have not expanded Medicaid coverage. In addition, some states are proposing plans to restrict eligibility for the Medicaid program or are increasing bureaucratic red tape for consumers who need coverage. Here are steps that states can take in 2019 to protect and improve their Medicaid programs:

Medicaid expansion. 

In 2018, Virginia adopted Medicaid expansion, becoming the first state to adopt an expansion in a state legislature since 2014. Three other states followed the example set by Maine in 2017 and put Medicaid expansion initiativeson the ballot in 2018. Idaho, Nebraska, and Utah passed ballot initiatives for expansion after state lawmakers and governors repeatedly refused to provide Medicaid coverage for adults and families. State lawmakers will take up implementation of these expansions in 2019, which will likely be on the legislative agenda in Kansas, North Carolina, and Wisconsin. States anticipating work on Medicaid expansion can find the Families USA Medicaid Expansion Toolkit here.

Medicaid restrictions. 

After federal officials opened the door to new restrictions on Medicaid coverage, some states chose to increase bureaucratic red tape for the eligibility process. Families USA’s Waiver Strategy Center provides tools and strategies for fighting such proposals, including requirements that people prove they work in order to receive and maintain Medicaid eligibility. California, however, provides a model for states seeking to go in the opposite direction. Learn about California’s law that prohibits work requirements and other restrictions on Medicaid eligibility. If you want to know more about the private health insurance pa then please send your queries by dropping a comment below.