qotd: Deloitte update of ACA Section 1332 state innovation waivers

Deloitte
Health Policy Brief
State health coverage innovation and Section 1332 waivers: Implications
for states
By Anne Phelps

Executive summary

Although states and the federal government have implemented most
Affordable Care Act (ACA) provisions, a few are scheduled to go into
effect in the coming years. One such provision is Section 1332 State
Innovation Waivers, (1332) which allows states to pursue alternative and
innovative strategies for ensuring that residents have access to
high-quality, affordable health insurance as long as they meet certain
requirements. Within the constraints of Section 1332, states have
numerous options for revamping their current approaches to providing
health coverage to individuals and families. If approved, the waivers
can go into effect beginning January 1, 2017. To implement reforms next
year and take advantage of realizing innovative alternatives for health
care coverage, states should consider acting now.

New guidance from the US Departments of Health and Human Services (HHS)
and Treasury released at the end of 2015 indicates that waiver proposals
from states using the federally facilitated health insurance exchange
might not be considered feasible at this time because "the Federal
platform cannot accommodate different rules for different states."
Instead, these states may want to consider establishing their own
exchange platform and then apply for a 1332 waiver.

This health policy brief presents a number of potential
waiver-associated coverage alternatives, including those being discussed
by some states. While some options are mutually exclusive, states may
include multiple innovative concepts in their applications. It is
important to note that, even with the new HHS and Treasury guidance, the
analysis required to support a 1332 waiver application may require
states to leverage actuarial, policy, technology, and data expertise.

A final consideration

As the United States moves closer to the next presidential election, the
health care landscape will continue to shift and evolve. Beginning in
2017, an Administration other
than the Obama Administration will have stewardship over the ACA and its
various provisions, including Section 1332 State Innovation Waivers, for
the first time. States should be aware that – depending on where they
are in the application process at the start of 2017 – approvals may
depend on the goals of the new Administration.

http://www2.deloitte.com/us/state-innovation-and-waivers

PDF of report (8 pages):
http://www2.deloitte.com/content/dam/Deloitte/us/Documents/life-sciences-health-care/us-dchs-state-health-innovation.pdf

***


Comment by Don McCanne

Section 1332 of the Affordable Care Act allows states to pursue waivers
allowing alternative approaches to implementation of the Act as long as
they comply with certain minimal requirements. In December, HHS released
an advisory which gives guidance to what sort of innovations might be
approved. This Deloitte health policy brief includes this guidance in
updating the description of Section 1332 waivers and how the states may
use them.

A few points:

* Section 1332 does allow innovations that can improve access and
equity and thus should be considered by state activists who wish to
improve their health care systems, though the innovations are quite limited.

* Section 1332 does allow innovations that might rely more heavily on
market dynamics and thus could threaten the social insurance gains of
ACA, though those innovations are also quite limited, but state
activists should be on guard to help protect what gains have been made.

* States with federally facilitated health insurance exchanges will not
be able to receive waivers because of the administrative complexity:
"the Federal platform cannot accommodate different rules for different
states."

* States that have not accepted federal funds to expand their Medicaid
programs may find that the political climate may inhibit any efforts to
improve their systems through waivers.

* The December 2015 advisory indicates that HHS will be quite rigid in
the interpretation of what innovations would be allowed. This will
protect states from efforts to dismantle the gains of ACA, but it will
also prevent states from using Section 1332 to establish a state-based
single payer system. Nevertheless, improvements such as all-payer
systems may be allowed, although the administrative requirements may be
overwhelming.

* The Deloitte report emphasizes the importance of politics: "Beginning
in 2017, an Administration other than the Obama Administration will have
stewardship over the ACA and its various provisions, including Section
1332 State Innovation Waivers, for the first time. States should be
aware that – depending on where they are in the application process at
the start of 2017 – approvals may depend on the goals of the new
Administration."

So this report does further confirm the fact that states can improve
their health systems through Section 1332 waivers. Until we can enact a
single payer national health program, state efforts should be pursued.

This report also confirms that state efforts alone are grossly
inadequate and that federal legislation for a national health program is
an imperative.

This year, single payer is back in the political arena. Although state
reform efforts are encouraged, we cannot allow these efforts to displace
or even dilute the drive for national single payer. Even if it is
difficult to see the political path to immediate enactment, at a
minimum, through education, grassroots and coalition efforts we can move
much closer to the political threshold required to make single payer
inevitable.

Read the Deloitte policy brief, give thought as to how far short Section
1332 waivers will leave us, and then join the national political
movement that will finally bring health care justice to all.