{"id":7106,"date":"2023-02-07T09:57:17","date_gmt":"2023-02-07T14:57:17","guid":{"rendered":"http:\/\/chirblog.org\/?p=7106"},"modified":"2023-02-07T09:57:53","modified_gmt":"2023-02-07T14:57:53","slug":"a-midterm-assessment-of-president-biden-promise-aca","status":"publish","type":"post","link":"https:\/\/chirblog.org\/a-midterm-assessment-of-president-biden-promise-aca\/","title":{"rendered":"A Midterm Assessment Of President Biden\u2019s Promise To Build On The ACA"},"content":{"rendered":"
By Sabrina Corlette and Joan Alker<\/em><\/p>\n As a presidential candidate, President Joe Biden promised that his administration would\u00a0protect and build on<\/a>\u00a0the Affordable Care Act (ACA). We\u2019re now halfway through President Biden\u2019s first term, making it a good time to assess the progress he has made to fulfil that promise, and what work there remains to do.<\/p>\n In January 2023, the state of health care coverage in the United States is the strongest it has ever been. This is in spite of unrelenting efforts by the Trump administration to undermine the ACA\u2019s coverage expansions and a worldwide pandemic that is now into its fourth year. Indeed, the ACA\u2019s Medicaid expansion and health insurance Marketplaces served as a critical coverage safety net during the economic disruptions caused by COVID-19. The uninsurance rate for non-elderly adults has\u00a0dropped<\/a>\u00a0from 10.9 percent in 2019 to 10.2 percent in 2021. Enrollment in Medicaid and the Marketplaces is at an unprecedented high\u201416.3 million people\u00a0signed up<\/a>\u00a0for a Marketplace plan for 2023, an almost 50 percent increase in enrollment since the president took office. As of September 2022, an\u00a0estimated<\/a>\u00a090.9 million people were enrolled in Medicaid and the Children\u2019s Health Insurance Program (CHIP), an increase of 28.6 percent since February 2020.<\/p>\n The coverage gains in the past two years are in large part due to legislative activity, including one major policy change signed into law by President Donald Trump. The\u00a0Families First Coronavirus Response Act<\/a>\u00a0(FFCRA) was enacted in March 2020 to provide urgently needed economic relief at the height of the COVID-19 shut downs. One of its provisions prohibited states from involuntarily disenrolling anyone from Medicaid as a condition of receiving enhanced federal funding for Medicaid during the national public health emergency. This provision has helped fuel the dramatic growth in Medicaid enrollment.<\/p>\n For his first two years in office, President Biden prioritized the ACA in his legislative agenda. Early in his term, he signed the\u00a0American Rescue Plan Act of 2021<\/a>\u00a0(ARPA), which included a significant increase in premium subsidies for Marketplace enrollees, through 2022. The ARPA also enhanced already generous federal financing available as an incentive to the 12 states (at the time) that had not yet expanded Medicaid\u2014although unfortunately only South Dakota, through a successful ballot initiative, has taken up the ARPA\u2019s fiscal boost. The ARPA further gave states the option to extend Medicaid coverage for 12 months for postpartum individuals, an option that has seen robust uptake by states. In September 2022, President Biden signed the\u00a0Inflation Reduction Act<\/a>, which included a continuation of the Marketplace enhanced subsidies through 2025.<\/p>\n More recently, the\u00a0Consolidated Appropriations Act of 2023<\/a>\u00a0allows states to resume Medicaid eligibility redeterminations paused since March 2020, and to disenroll those they find ineligible or who fail to successfully complete the renewal process starting April 1, 2023. This Medicaid \u201cunwinding\u201d process could dramatically reduce the country\u2019s recent coverage gains, with an estimated\u00a018 million<\/a>\u00a0expected to have their Medicaid coverage discontinued. Federal\u00a0estimates<\/a>\u00a0project that 6.8 million Medicaid beneficiaries (of whom 5.3 million are children) will lose coverage despite remaining eligible due to administrative issues such as long call center wait times, missed deadlines, and returned mail; the vast majority of these are likely to become uninsured at least for some period of time.<\/p>\n For the past two years of President Biden\u2019s term, legislative action to expand the ACA is unlikely. The now Republican-led US House of Representatives is likely to block any such efforts. This will leave executive branch action as the primary locus for activity.<\/p>\n In its first two years, the Biden administration made extensive use of its executive branch powers to expand and improve the coverage available through the Marketplace. Another top priority has been rolling back Trump-era actions limiting access to Medicaid and the Marketplace. These executive branch actions include executive orders, regulations, guidance to health plans and other regulated entities, state waiver approvals and rescissions, funding, and operational upgrades. Below, we summarize some of the most significant administrative actions to date.<\/p>\n One of the most impactful actions the Biden administration has taken may be its significant\u00a0investment<\/a>\u00a0in outreach and consumer enrollment assistance. Combined with more affordable Marketplace premiums, this additional support has driven Marketplace enrollment to historic heights. Additional critical administrative actions to expand Marketplace enrollment and improve access to care have included:<\/p>\n The FFCRA\u2019s continuous coverage provision has been the major driver of coverage gains associated with Medicaid. However, the Biden administration has sought to advance coverage, access, and health equity goals through section 1115 waiver policy and regulatory activity.<\/p>\n An early priority for the Biden administration was the rescission of approved section 1115 demonstrations that allowed states to condition Medicaid eligibility on\u00a0work requirements<\/a>. Such waivers had been approved in 13 states by the Trump administration; in the first few months after taking office, the Biden administration rescinded them all\u2014although a recent\u00a0court order<\/a>\u00a0reinstated Georgia\u2019s approval.<\/p>\n Additionally, the White House released a major new maternal health\u00a0blueprint<\/a>\u00a0in June 2022, and has encouraged states to take up the new 12-months postpartum coverage option. States have been rapidly adopting the new option, with\u00a034 states and the District of Columbia<\/a>\u00a0moving forward as of this writing.<\/p>\n More recently, the administration had advanced its coverage and health equity goals by approving section 1115 waivers such as\u00a0Oregon<\/a>\u2019s Health Plan, which breaks new ground by offering continuous eligibility for children 0\u20136 years old and two years of continuous eligibility for everyone else.<\/p>\n By any measure, the Biden administration has made tremendous progress to fulfil its promises on the ACA, while simultaneously managing a worldwide pandemic and implementing other key health bills, such as the\u00a0No Surprises Act<\/a>. However, there remains considerable work on the regulatory agenda. Below we summarize some key policies the administration is likely to advance in the next two years.<\/p>\n To build on the ACA, President Biden must undo his predecessor\u2019s efforts to undermine the law. The Trump administration adopted two policies designed to roll back the ACA\u2019s insurance reforms: encouraging the sale of\u00a0short-term insurance products<\/a>\u00a0exempt from the ACA\u2019s consumer protections and enabling insurers to market\u00a0association health plans<\/a>\u00a0that do not have to comply with the ACA\u2019s rating protections for small employers and individuals. The Biden administration has\u00a0signaled<\/a>\u00a0its intention to reverse both of these policies.<\/p>\n The administration also has sought\u00a0public input<\/a>\u00a0on the current definition of the ACA\u2019s essential health benefit (EHB) standard, consistent with a statutory requirement that the Secretary of the Department of Health and Human Services periodically review and update the EHB to address any gaps in access to coverage or changes in medical evidence. Such a request is usually a precursor to federal rulemaking.<\/p>\n The Biden administration is also expected to soon finalize its interpretation of\u00a0section 1557<\/a>\u00a0of the ACA, which prohibits discrimination on the basis of race, color, national origin, sex, age, or disability under any federally supported health program. It is expected that the rule will extend nondiscrimination protections to LGBTQ people (reversing a Trump-era interpretation), strengthen language access requirements, and prohibit the use of discriminatory algorithms in health care decision making.<\/p>\n One of the\u00a0Biden administration\u2019s priorities<\/a>\u00a0for Medicaid and CHIP is to streamline eligibility and enrollment processes and remove barriers to coverage such as waiting periods for children in CHIP. Other rules due to be finalized include guidelines for mandatory state reporting of Child\u00a0Core Set quality measures<\/a>\u00a0for Medicaid and CHIP and Adult Behavioral Health quality measures.<\/p>\nThe Big Picture<\/h2>\n
Looking Back: The Biden Administration Has Leveraged Executive Branch Powers To Expand Coverage Access<\/h2>\n
Expanding Access And Affordability In The ACA Marketplaces<\/h3>\n
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Strengthening Medicaid, Improving Maternal Health, And Advancing Equity<\/h3>\n
Looking Ahead: Unfinished Business For The Executive Branch<\/h2>\n
Stabilizing And Improving Coverage And Equity In The Private Insurance Market<\/h3>\n
Strengthening Medicaid And CHIP<\/h3>\n