Republican leaders in both Houses of Congress reached an agreement in principle on a bill that would fund the cost-sharing reduction (CSR) program for two years if the legislation incorporates "structural reforms" to the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148). House Ways and Means Committee Chair Kevin Brady (R-Texas) and Senate Finance Committee Chair Orrin Hatch (R-Utah) announced the agreement, though no legislative language has been released.
CSR funding. Section 1402 of the ACA allows for reduced cost sharing for individuals enrolling in qualified health plans (QHPs). The HHS Secretary determines whether an individual enrolled in a QHP is eligible for a CSR based on his or her annual income and family size; the Secretary then notifies the issuer of the plan of that eligibility, and the issuer reduces cost sharing under the plan. After the reductions are made, the plan issuer notifies the Secretary, who "shall make periodic and timely payments to the issuer equal to the value of the reductions." According to Republican members of Congress, the ACA makes no specific appropriation for payments under Section 1402. The Trump Administration agreed, and recently terminated CSR payments (see Trump terminates CSR payments, October 18, 2017). The deal announced by Brady and Hatch would fund CSRs through 2019, but would require insurers to "meet certain conditions," including "pro-life protections." It is unclear what the conditions or protections would entail.
Structural reforms. The agreement requires the incorporation of "structural reforms" to the ACA. Specifically, it would require a five-year suspension (until 2021) of the ACA’s requirement that most individuals maintain health insurance, and a two-year penalty exemption (for 2015 through 2017) for employers that did not provide insurance coverage based on the ACA’s employer mandate. Without the individual mandate, however, many insurers would refuse to participate in the exchanges, negating the need for CSR payments. The agreement would also expand health savings accounts (HSAs) to increase the maximum contribution limit.
Comparison to Alexander-Murray. The Hatch-Brady agreement is a stark contrast to the bipartisan agreement announced recently by the Chair and Ranking Member of the Senate Committee on Health, Education, Labor and Pensions, Sens. Lamar Alexander (R-Tenn) and Patty Murray (D-Wash) (see Bipartisan ACA deal announced, October 18, 2017). The Alexander-Murray bill, which is cosponsoredby 22 Senators (11 Republicans, 10 Democrats, and one Independent who caucuses with Democrats), came after four Committee hearings on problems with the ACA. It would appropriate CSR payments, increase access to low-premium high-deductible health plans on the ACA exchange, and expand Section 1332 State Innovation Waivers. That agreement does not change either the individual or employer mandate, or change the essential health benefits that must be covered by all health insurance plans. It is uncertain, however, whether Republican leadership in the Senate and House would bring the Alexander-Murray legislation to a floor vote.
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