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5 health care predictions for 2018

The habit they can’t quit: Congress will likely revisit changes to Obamacare in the new year.

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President Trump gave an interview to the New York Times that included this very rambling sentence on association health plans:

So now I have associations, I have private insurance companies coming and will sell private health care plans to people through associations. That’s gonna be millions and millions of people. People have no idea how big that is. And by the way, and for that, we’ve ended across state lines. So we have competition. You know for that I’m allowed to [inaudible] state lines. So that’s all done.

Lucky for all of us, my VoxCare co-writer Dylan Scott has a great piece on what association health plans are, and how the Trump administration recently used an executive order to expand them.

2018 health policy predictions!

Some people like to start a new year with resolutions. I, however, have a bit of a different tradition: trying to figure out what the heck is going to happen in health care.

This past year has been full of unpredictable twists and turns in health policy, right down to Sen. John McCain's (R-AZ) 2 a.m. thumbs-down vote that sunk the Senate health care bill.

So what does 2018 have in store for us? Here is a far from complete list of what I'm expecting in the new year, and what I'll be watching as 2018 begins.

Congress revisits Obamacare. Like that terrible habit you can't quite kick, I'm guessing we see at least one more attempt at a major Obamacare overhaul bill in the new year.

Yes, I know Senate Majority Leader Mitch McConnell has said it's time to move on. But remember what happened when House Speaker Paul Ryan declared Obamacare "the law of the land," moments after their first repeal efforts failed? Republicans have found it really hard to quit the Obamacare repeal fight after promising action for nearly a decade.

And next year may be even harder to quit. A few weeks ago, Axios's Sam Baker made a convincing argument for why the tax bill actually makes it more likely that Republicans will work on health care in 2018. The repeal of the individual mandate may cause some state marketplaces to fall into collapse, as insurers no longer want to sell in an environment where healthy people are not required to purchase coverage.

The ensuing mess may make it really hard for Congress to avoid doing something to stabilize the marketplaces. Maybe it's Alexander-Murray, maybe it's something we haven't seen yet, maybe it's not even branded as Obamacare repeal but as Republicans creating their own health care program. Whatever it is, I think there is a good chance that the Ghosts of Health Care Bills Past keep stalking around Capitol Hill for another year.

Some states work to pass their own individual mandates. The new tax law ends the Affordable Care Act's requirement that nearly all Americans purchase health insurance coverage or pay a fine. In response, I'm expecting to at least a few states that support the health care law work to pass their own, state-level mandates. So far, we've seen some rumblings of action from California, Maryland, the District of Columbia and Washington State (and Massachusetts, of course, already has a mandate from its 2006 reforms).

I'm expecting to see a few more states that manage their own marketplaces try to take action on this issue, although it's anyone's guess which ones. Not all of these efforts will pass — and some might test out different ideas for encouraging people to buy health insurance, like a late enrollment penalty or higher premiums for those who have a break in coverage.

Medicaid sees big changes — ones the Obama administration blocked. About a half-dozen states want to make some big changes to Medicaid. They want to add in things like work requirements, small premiums for low-income enrollees, and (in the case of Wisconsin) drug testing for beneficiaries.

These waiver requests have been sitting with Medicare administrator Seema Verma, many for months now. Verma is generally supportive of these approaches to Medicaid policy. She gave a speech this fall to the National Association of Medicaid Directors in which she said this:

For people living with disabilities, CMS has long believed that meaningful work is essential to their economic self-sufficiency, self-esteem, wellbeing, and improving their health. Why would we not believe that the same is true for working-age, able-bodied Medicaid enrollees?

Believing that community engagement requirements do not support or promote the objectives of Medicaid is a tragic example of the soft bigotry of low expectations consistently espoused by the prior administration. Those days are over.

I've been a bit surprised that these waivers haven't been approved yet. Keen observers of the Medicare agency have argued that staff have their hands quite full, between Obamacare repeal efforts and a slew of executive orders and new regulations that they've put out in 2017. In any case, I'm certainly expecting to see movement on these waivers next year — and that would mean really significant change for Medicaid. Never before has the federal government required low-income Americans to work in order to receive their federal health benefits. But that is likely about to change.

CHIP gets funded — or faces a major crisis. It is still shocking to me that we leave 2017 with the CHIP program soon to expire. States are starting the new year with the quite real possibility of shutting down their health program for low-income kids within the next month. Connecticut, Alabama, and Colorado have all issued notices to CHIP families saying that, unless there is action from Congress, the program will sunset on January 31.

I don't think it will get to that point. Faced with the possibility of hundreds of headlines about children losing access to medical care, I have to imagine Congress will decide to act. But then again, I expected them to act months ago. CHIP has a history as a bipartisan health care program, a scenario much different from the Affordable Care Act. One of its longtime champions is Sen. Orrin Hatch (R-UT) who chairs the powerful Senate Finance Committee.

But so far, that bipartisan history hasn't done much to help CHIP in 2017. We'll see if that changes in the year to come.

One state tests out a new way to expand health insurance. The Republican efforts to repeal the Affordable Care Act seem to have catalyzed more thinking and interest from liberals on how to expand public health insurance coverage.

One place you see this is growing support among Democratic senators for a Medicare-for-All bill. But another place that I'm watching is state legislatures, which have also shown interest in testing out some novel policy ideas for expanding health coverage.

This year, for example, Nevada got pretty close to enacting the country's first Medicaid buy-in, which would allow any state residents to purchase coverage through the program traditionally reserved for low-income Americans. That plan passed the Nevada legislature but was vetoed by Gov. Brian Sandoval, a Republican.

But Medicaid buy-in isn't dead. I've talked to gubernatorial candidates in Connecticut and Colorado who are campaigning on the same idea. And I've also heard from some state legislators in Washington State (where the legislature recently flipped blue) who are exploring a Nevada-style bill too.

When it comes to health policy, states truly are the laboratories of democracies. It was the Massachusetts 2006 health care expansion, for example, that came to be the model for a national Affordable Care Act. In the coming year, I'm expecting to see more bills like the one in Nevada that encourage new ways of thinking about the best way to provide health coverage.

Chart of the Day

Javier Zarracina/Vox

If you're thinking about diet-related New Year's resolutions, you might want to check out this chart. Vox's Julia Belluz astutely observes that many of our favorite breakfast foods often have as much sugar as cookies and candy bars. Read more from her here.

Kliff’s Notes

With research help from Caitlin Davis

Today's top news

  • “Healthcare.Gov Sign-Ups Tick Down To 8.7 Million In Final Numbers Release”: “A report on HealthCare.Gov enrollment released by Centers for Medicare & Medicaid Services on Thursday showed the final number of sign-ups on the federal Obamacare exchanges to be about 100,000 fewer than the numbers released last week.” —Tierney Sneed, Talking Points Memo
  • “Feds tinker with Medicare Advantage risk payments”: “The Centers for Medicare and Medicaid Services has proposed a new way to pay health insurance companies that sell Medicare Advantage plans to more than 20 million seniors and disabled people. The new payment model is complex, but it will affect billions of dollars starting in 2019 and will change how insurers code their sickest members.” —Bob Herman, Axios
  • “CMS approves first 10-year waiver extension in Mississippi”: “The waiver will allow the state to provide further coverage of family planning services. It extends eligibility for women and men ages 13 through 44, with incomes up to 194 percent of the federal poverty level who are not enrolled in Medicaid, Medicare, the Children's Health Insurance Program or other creditable health insurance coverage that includes family planning services, CMS said.” —Susan Morse, Healthcare Finance

Analysis and longer reads

“A third of Americans believe Obamacare has been repealed: Poll”: “The findings from YouGov show that 31 percent of respondents agreed that Trump had kept his campaign promise to repeal Obamacare. The largest plurality of people who agreed with the statement by age were 65 and older, at 38 percent.” —Kimberly Leonard, Washington Examiner

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