The midterm elections are upon us, and most voters view health care as a “very important” issue. Although Congress recently acted to improve the affordability of health insurance and prescription drugs through the Inflation Reduction Act, the law passed without a single Republican vote in the House or the Senate. Instead, Republican members of the House of Representatives have put out their own, separate health policy agenda through their Healthy Future Task Force.

Since announcing its creation last year, the Republican task force has put out a series of recommendations relating to health care modernization, treatment, security, doctor-patient relationships, and affordability. This post focuses on several of the task force’s affordability recommendations,* which signal the approach to health insurance reform House Republicans may take if they regain the majority in the midterm elections.

Many Task Force Proposals Create Haves and Have-nots

Although the task force predominately published high-level talking points about affordability, rather than detailed policy proposals, common themes include “choice,” “innovation,” and reducing “burdensome regulations.” Taken together, the proposals would effectively lower federal standards for health insurance. Such policies will always create winners and losers.

State Innovation at the Cost of Consumer Protections

The task force has proposed “[e]mpower[ing] states to approve health insurance plans more suitable to their constituents’ needs by lifting burdensome regulations that require cookie-cutter coverage.” The language suggests a desire to lower the federal floor set by the Affordable Care Act (ACA) and allow states to create their own set of rules for health insurance, which may jeopardize consumer protections such as pre-existing condition coverage requirements, Essential Health Benefits (EHB), and prohibitions against annual and lifetime benefit limits.

The ACA was enacted to put an end to the patchwork of state standards for health insurance. The “burdensome regulations” the task force seeks to lift are in place to protect sick people, women, and others who were discriminated against in the pre-ACA individual market. When Idaho tried to illegally waive some of the ACA’s requirements for health insurance sold in the state, products developed by insurers imposed waiting periods for pre-existing condition coverage, set premiums based on health status, and failed to cover all of the EHB categories, such as maternity care. While federal regulators put a stop to Idaho’s “innovative” plans, the Healthy Future Task Force proposal would embrace this type of state action. While states can “innovate,” without a federal floor for coverage, this flexibility comes at a high price for consumers who may face medical underwriting, benefit exclusions, and other discriminatory industry practices that the ACA sought to end.

Policies to Reform Employer Coverage Would Lead to More Health Insurance Haves and Have-Nots

Many of the task force affordability proposals center on improving health insurance options for workers and their employers. Nearly half of Americans get health insurance through an employer, and rising costs make job-based coverage ripe for reform. Still, some policies outlined by the task force cater to the healthy and wealthy, leaving many workers behind.

Association Health Plans

The task force recommends letting small business owners “join together through Association Health Plans” (AHPs) to achieve “economies of scale that large companies enjoy” as a way to provide employees with more affordable health insurance. AHPs are not a new idea—in fact, a long history of insolvency, fraud, and negative market impacts has plagued this coverage arrangement. Following the ACA, AHPs had to comply with individual and small-group market requirements. But in 2018, the Trump administration promulgated rules that would allow these arrangements to skirt many of the ACA’s protections to the detriment of small employers and individuals with greater health care costs, and potentially destabilizing the ACA-compliant individual and small-group markets. Indeed, the federal judge who struck down the Trump-era rule pointed out that relying on AHPs to expand health insurance is “clearly an end-run around the ACA.”

Health Savings Accounts

The task force also looks to a frequent Republican health policy proposal: expanding health savings accounts (HSAs). These tax-advantaged accounts, which are paired with high-deductible health plans, rely on consumers having expendable income to deposit in order to afford out-of-pocket costs. Accordingly, they predominately benefit consumers with higher incomes.

In addition to proposing expansion of telehealth coverage through HSAs, the task force recommends “removing unnecessary red tape.” This recommendation suggests an intent to lower federal guardrails and make the already highly regressive HSAs more attractive for the people that they benefit—the wealthy who already have access to health insurance—while doing nothing to help low-income and uninsured consumers afford coverage

Proposals to Promote Health Care Price Transparency Could Improve Affordability, but the Devil’s in the Details

A number of proposals for improving affordability center on price transparency. Transparency could help to slow rising cost of health care that is ultimately borne by consumers, but implementation issues may short-circuit the success of these policy proposals.

Mere Codification of Trump-era Transparency Rules Fails to Tackle Enforcement Issues

The task force recommends codifying the Trump administration’s rules on price transparency. These rules, which require hospitals and insurers to publish their prices, aim to drive competition in the health care market to reduce costs. Codifying the rules into legislation would make the transparency requirements more durable, but baking in the current regulations would not solve the present compliance and access issues that have made price data less than useful. Stakeholders have identified several ways to improve the transparency rules; simply codifying existing regulations would not implement the policy fixes needed for price transparency to meaningfully lower costs. If Congress does decide to move on price transparency, establishing an effective enforcement mechanism will be crucial to the policy’s success.

Advanced Explanation of Benefits Could Significantly Improve Transparency for Patients

One of the task force’s policy proposals enjoying bipartisan support is implementation of a No Surprises Act (NSA) provision: the advanced explanation of benefits (AEOB). AEOBs would allow consumers in certain situations to receive information about their cost-sharing responsibility prior to receiving care. The Biden administration delayed implementation of this provision, citing challenges related to the transmission of information between providers and insurers, and recently released a Request for Information on AEOBs.

As the task force proposal notes, AEOBs would offer patients nearly “unprecedented” transparency regarding health care costs. The delay of implementing this proposal could be driven in part by industry opposition. Like the transparency rules, the underlying challenge is implementation of an existing policy. Congress can play an important role by encouraging the Biden administration to move forward expeditiously with the operational requirements that providers and insurers need to comply with this long-delayed and important tool for consumers.

Takeaway

After years of failed attempts repeal and replace the ACA, Republicans in Congress have largely abandoned the effort. Health care affordability does not appear to be a central tenet of the House Republicans’ agenda released ahead of the midterm elections, and in fact several candidates have reversed course after their health policy proposals backfired. However, House Republicans have published recommendations that impact health insurance access, affordability, and adequacy. In addition to the task force proposals, the Republican Study Committee—a conservative House caucus—wants to convert funding for the ACA’s marketplace subsidies and Medicaid to block grants, severely limiting federal dollars for programs that help low- and moderate-income consumers access insurance. If Republicans do obtain a majority in Congress, such proposals may form the basis of their policy agenda. It is worth considering the potential consequences for consumers.

*Author’s Note: This is not an exhaustive analysis of all Healthy Future Task Force recommendations for improving health care affordability—it focuses on several proposals likely to impact individuals and families that enroll in private coverage. Because the task force modernization proposals include a policy regarding telehealth coverage, this post also discusses a proposal from the task force modernization subcommittee.