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The Repeal and Replace Architects: How Two Key Players Could Shape the Future of the ACA (Part II)

 

With Donald Trump taking office as the 45th President of the United States on January 20th, there has been a great deal of debate over the fate of the ACA.

As mentioned in part I of this two part series, Paul Ryan and Tom Price are key players in the effort to repeal and replace our current healthcare system. With Speaker Ryan's A Better Way previously outlined and Representative Price's proposal below, it's easy to draw comparisons and distinctions between these two plans.

Part II:

Tom Price
Empowering Patients First Act (HR 2300)

Georgia’s 6th District Congressman, Tom Price, M.D., is the Trump Administration nominee to head the Department of Health and Human Services. In Congress, Price currently serves as Chairman of the House Committee on the Budget and is a member of the House Committee on Ways and Means. Both Committees have jurisdiction over a variety of government spending programs, including healthcare.

During the 111th (2009-2010), 112th (2011-2012) and 113th (2013-2014) Congress, Price introduced the Empowering Patients First Act. When this legislation was first introduced, it was intended to be a Republican alternative to Democratic efforts to reform the healthcare system.

However, the current version of this bill calls for the full repeal of the ACA with more patient-centered solutions.

Outlined below are 10 focus areas of the Empowering Patients First Act:

TITLE I:  Tax Incentives for Maintaining Health Insurance Coverage

  • Refundable Tax Credit for Low Income Individuals to Buy Health Insurance:
    • The amount would be tied to the average insurance cost on the individual market tied to inflation.
  • Advance Payment of Credit as Premium Payment for Qualified Health Insurance:
    • Provides for the advance payment to be sent to the insurer or issuer on behalf of the individual.
  • Election of Tax Credit Instead of Government or Group Benefits:
    • Any individual insured via a government plan or an employer plan could opt out and receive the tax credit instead.
    • Medicare opt outs would not lose Social Security Benefits.
  • Deduction for Qualified Health Insurance Costs of Individuals:
    • Anyone purchasing individual health insurance can do so with pre-tax dollars.
    • Deduction would be capped at the average national health exclusion for employer-sponsored insurance.
  • Limitation on Abortion Funding:
    • No federal funds, credits or deductions allowed to be used to pay for abortion services.
  • No Government Discrimination Against Certain Healthcare Entities:
    • Prohibits the discrimination of any individual or healthcare facility that does not provide, cover or pay for abortions.
  • Equal Employer Contribution Rule to Promote Choice:
    • Allows employer to grant all employees with a pre-tax benefit – defined contribution.
    • Employee could elect employer or individual market plans.
  • Limitations on State Restrictions on Employer Auto-Enrollment:
    • As long as employees can opt out of coverage, employers can auto enroll for health insurance.
    • States may not preclude this approach.
  • Credit for Small Employers (50 and under) adopting Auto-Enrollment and Defined Contribution Options:
    • $1,500 grants to incentivize this approach.
  • S.A. Modification and Clarification:
    • Qualified medical expenses to include pre-paid physician fees, concierge or direct practice medicine.

TITLE II:   Health Insurance Pooling Mechanisms for Individuals

  • Federal Grants for State Insurance Expenditures:
    • States may receive grants for establishing high risk or reinsurance pools for the individual market.
    • $300 million divided by states.
    • Bonus grants available.
  • Expansion of Access and Choice Through Individual Membership and Small Employer Membership Associations (IMAs):
    • Allows for establishment of Association health insurance plans.
    • IMA’s would be exempt from state benefit mandates.
    • IMA coverage only allowed via contracts with health insurance issuers; can’t assume risk.
  • Small Business Health Fairness Act (AHP):
    • Allows small businesses to establish association plans across state lines.
    • Requires solvency standards to protect patients and ensure benefit payments.

TITLE III:  Interstate Market for Health Insurance

  • Cooperative Governing of Individual Health Insurance Coverage:
    • Allows insurers to sell policies to residents of any other state.

TITLE IV:  Safety Net Reforms

  • Requiring Outreach and Coverage Before Expansion of Eligibility:
    • States must demonstrate that their funding allotment covers at least 90% of the State Children’s Health Insurance Program (SCHIP) eligible children and pregnant women in their state.
  • Easing Administrative Barriers to State Cooperation with Employer- Sponsored Insurance Coverage:
    • Requires states to include pathways for premium assistance for employer-sponsored insurance.
    • States must offer a form of employer-sponsored coverage for SCHIP and Medicaid beneficiaries.
  • Improving Beneficiary Choices in SCHIP and Medicaid:
    • States shall make available the purchase of private insurance as an option to their Medicaid and SCHIP populations.

TITLE V:   Lawsuit Abuse Reform

  • Change in Burden of Proof Based on Compliance with Best Practices Guidelines:
    • The Secretary of Health and Human Services (HHS) will work with the Physicians Consortium for Performance Improvement (PCPI) and medical specialty societies to develop best practice guidelines for the evaluation and treatment of medical conditions.
    • Guidelines will be used to provide defense in a lawsuit and afford a defendant the ability to not be held liable unless clear and convincing evidence establishes otherwise.
  • State Grants to Create Administrative Healthcare Tribunals:
    • Secretary of HHS may award grants to states to establish administrative healthcare tribunals.
    • Each case would be reviewed by panel and receive a recommendation regarding liability and compensation.
  • Authorization of Payment of Future Damages to Claimants in Healthcare Lawsuits:
    • Provides for periodic payments of future damage awards over $50,000.

TITLE VI:  Wellness and Prevention

  • Providing Financial Incentives for Treatment Compliance:
    • Amend HIPAA wellness regulations to increase incentive variation from 20% to 50%.

TITLE VII:  Transparency and Insurance Reform Measures

  • Receipt and Response to Requests for Claim Information:
    • Within 30 days of request, a health insurance issuer must provide detail claims information to employer groups with 50 or more employees.
    • Insurer would not be required to provide a report more than twice in twelve months.
  • Prohibition on Certain Uses of Data Obtained from Comparative Effectiveness or Patient-Centered Outcomes Research; Accounting for Personalized Medicine and Difference in Patient Treatment Response:
    • Secretary of HHS prohibited from using outcomes research to deny coverage of an item or service under a Federal healthcare program.
    • Prohibits release of findings in final form until after consultation and approval by relevant physician specialty organizations.
  • Establishment of Performance-Based Quality Measures:
    • Requires the Secretary of HHS to submit a formalized process for the development of performance-based quality measures that could be applied to physicians under the Medicare program.

TITLE IX:   State Transparency Plan Portal

  • Health Plan and Provider Portal to Provide Standardized Information:
    • A state may establish a Health Plan and Provider Portal for the purposes of providing standardized information on certified plans, price and healthcare providers.

TITLE X:   Patient Freedom of Choice

  • Guaranteeing Freedom of Choice and Contracting for Patients under Medicare:
    • Allows Medicare beneficiaries to voluntarily enter into contracts with participating and non-participating Medicare eligible professionals without penalty.
    • Contract may not be entered into when the Medicare beneficiary is facing an emergency medical condition or urgent care situation.
  • Preemption of State Laws Limiting Charges for Physician and Practitioner Services:
    • A state may not impose a limiting charge for services provided by eligible professionals for which Medicare payment is made.
  • Healthcare Provider Licensure Cannot be Conditioned on Participation in a Health Plan:
    • Prohibits the Secretary of HHS or any state from conditioning a healthcare provider’s licensure on participation in any health plan.
  • Bad Debt Deduction for Doctors to Partially Offset the Cost of Providing Uncompensated Care Required Under Amendments Made By the Emergency Medical Treatment and Labor Act:
    • Amends the IRS code to allow certain physicians to deduct costs associated with uncompensated care for services to emergency room patients and pregnant women in

As you can see, there is certainly overlap in a variety of areas between A Better Way and the Empowering Patients First Act. The race to repeal and replace started on January 20th and it will be interesting to see which elements of these two proposals become fundamental in the effort to replace the ACA. We will continue to provide timely updates and insight into each of these proposals and/or others that may unfold with the impending administration turnover.

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