Health Care Policy 2019: What Employers Need to Know at the Mid-Year Mark
  • Health Care Policy & Compliance

Health Care Policy 2019: What Employers Need to Know at the Mid-Year Mark

U.S. health care policy – and the Affordable Care Act (ACA), in particular – may not be grabbing headlines in 2019 like it has in recent years, but that doesn't mean that employers can stop paying attention.

Here's a mid-year update on some key policy issues impacting employer-sponsored health care and benefits:

ACA Legal Challenge

In December 2018, a federal district court judge in Texas ruled in favor of the plaintiff in a lawsuit challenging the constitutionality of the ACA's individual mandate and, with it, the entire health care law.

The judge concluded that, since Congress eliminated the fine for not complying with the individual mandate, the mandate is no longer permissible under Congress’s taxing power and is therefore unconstitutional. And because the individual mandate is essential to and inseparable from the ACA, the judge argued, the entire law should be invalidated. However, the ruling did not enjoin the ACA, meaning that the law’s provisions remained in effect pending an appeals process.

Since then, the Trump Administration has formally declared its opposition to the entire ACA, abandoning its earlier position that some portions of the law, including the provision allowing states to expand their Medicaid programs, should stand. This move likely will put health care near the top of the list of issues at play during the 2020 elections.

For now, the Fifth Circuit Court of Appeals will hold oral arguments on the Texas lawsuit in mid-July, with a final ruling expected sometime in the fall of 2019. Regardless of how the appeals court rules, the case will almost certainly make its way to the Supreme Court—meaning the ACA will remain the law of the land for the foreseeable future.

Surprise Medical Bills Legislation

Chances are you or someone close to you has experienced one of the following health care scenarios:

  • A patient is treated at an in-network hospital by an out-of-network provider
  • A patient is treated at an out-of-network hospital during an emergency situation

In each case, the patient is likely unaware they're receiving out-of-network at the time. But what often ends up happening is that the patient's health insurance plan only pays the provider an amount equal to the plan's in-network rates, leaving the patient responsible for the amount over-and-above the in-network rate—what's known as a “balance bill.” Needless to say, the unexpected expense can place a significant burden on the patient.

To date, at least 15 individual states have enacted some sort of protection against such scenarios. And now, the federal government is getting involved.

There is undisputed, bipartisan support for protecting patients from surprise medical bills. But the issue is, if patients aren't required to pay these balance bills, who will? How much should the health insurance plan pay?

Several bills have been drafted to take aim at surprise medical bills. Here's how they propose to handle the excess payments:

House Energy & Commerce Committee Bi-Partisan Bill

  • Patients would only pay in-network rates to out-of-network providers
  • The excess amounts would be payable by the insurance plan, equal to the plan’s own median in-network rate for the relevant medical service in a geographic area

Senators Cassidy (R-LA) and Hassan (D-NH) Bi-Partisan Bill

  • Excess amounts payable by the insurance plan would be determined through arbitration
  • Final decision would be based upon commercially-reasonable rates in the geographic area

Senate HELP Committee Bi-Partisan Bill

  • Option 1: In-network hospitals must ensure everyone working there is also in-network; the insurance plan would pay the provider the plan’s own median contracted rate for the geographic area
  • Option 2: Disputed bills under $750 would be payable at in-network rates; anything over $750 would be decided through arbitration
  • Option 3: The excess payment would be equal to the median contracted rate for the geographic area

Much remains to be ironed out with these proposals, and providers and insurance carriers will certainly make their opinions known, but it would appear that the days of surprise medical bills might be numbered.

Learn more about current health care policy issues impacting employer-sponsored health care and benefits – including HRAs and AHPs – in this on-demand webinar featuring insights and commentary from leading health care policy expert Chris Condeluci.