The Health 202: States pursue public health coverage even as Trump administration emphasizes private




The Trump administration has promised states more flexibility in how they run their Obamacare marketplaces. But creating a state-backed “public option” plan may not be what Centers for Medicare and Medicaid Services Administrator Seema Verma had in mind.

Half a dozen states are looking into creating a public option — either as a stand-alone plan or a buy-in to Medicare or Medicaid — hoping to entice more of the uninsured by offering a more affordable choice. It’s an idea Congress considered but then discarded while writing the 2010 health-care law, but is now increasingly touted by Democrats as a way to achieve universal coverage.

But states may be limited in how far they can go. They need to ensure the plans closely mirror coverage already being sold in the marketplaces — otherwise, they must request permission via waivers from the Trump administration, which has emphasized private health options and has appeared less enthusiastic about an expansion of government-backed coverage.

That’s something Washington state specifically tried to avoid. The state is working on launching a public option by 2021, which will offer somewhat lower premiums than its marketplace competitors by paying lower rates to doctors, hospitals and other health providers.

To avoid any potentially messy run-ins with CMS, Washington will provide coverage through a commercial plan that is already approved to sell on the marketplaces. State legislators considered requesting a waiver from CMS so they could undertake more ambitious changes — like structuring the plan’s subsidies in alternative ways or trying to capture more savings — but ultimately rejected that idea.

“We ruled it out early on because we didn’t want to even ask,” said Jason McGill, senior health policy advisor to Gov. Jay Inslee, a 2020 presidential candidate. “We felt that it would have been a non-starter with the current administration.”

The administration has made clear what kinds of things it would approve: Moves by states to ease Obamacare requirements or let states apply its subsidies to leaner, cheaper plans. Verma has frequently criticized the Affordable Care Act as overbearing, stressing that the agency is doing everything it can to ease the law’s requirements.

Verma has also been publicly critical of Medicare-for-all ideas advanced by Democrats on Capitol Hill, warning that they’d ruin the current Medicare program and calling the proposals “the greatest threat to the American health-care system.” CMS didn’t respond to a request about how it would respond to a state waiver request for creating a public option.

“When you look at the new guidance, there’s an emphasis on private options,” said Chiquita Brooks-LaSure, managing director for Manatt Health. “We would just have to see what the administration would say if a state came up with a waiver proposal.”

Other states are also eyeing public option plans, although their progress has been slow. New Mexico has formed a working group and set aside $140,000 to examine the idea after abandoning an original proposal to create a Medicaid buy-in. Colorado passed a bill directing state agencies to draft a plan by November for how a public option could be designed and how it would be sold.

The Connecticut House passed a public option bill this spring, although it later stalled in the Senate. The Nevada legislature passed a public option bill two years ago, but it was vetoed by Republican Gov. Brian Sandoval. Public option bills have been proposed in Maine, Massachusetts, Minnesota, Missouri, New Hampshire, New Jersey and Oregon.

United States of Care, a group formed by former CMS Administrator Andy Slavitt, recently released a playbook for states considering a Medicaid buy-in — a form of a public option plan.

There’s a clear problem many of these states are trying to solve: Obamacare plans that, for many Americans, are still too expensive. While there are signs the marketplaces have been stabilizing, costs are still prohibitive for many consumers, especially those who qualify for only minimal subsidies or none at all.

The average monthly premium for a 40-year-old purchasing a mid-range “silver” plan on the marketplaces is $495 before subsidies, according to research by the Kaiser Family Foundation. And then there are hefty plan deductibles; the average annual silver plan deductible for medical and prescription drug coverage is $4,375, according to the KFF.


AHH: Democrats are poised to vote this week on a bill funding the Department of Health and Human Services that includes the Hyde Amendment. The longstanding provision, which bans taxpayer funding of abortion in most circumstances, got attention last week when former vice president Joe Biden said he continues to support Hyde but then suddenly reversed his support under heavy pressure from liberals. 

Some of his rivals who slammed Biden for supporting Hyde have voted numerous times for spending bills that have included the provision, and will get the chance to do so again, as we wrote in Friday’s Health 202.

“The delicate straddle Democrats are performing reflects a long-standing dilemma: The federal funding restriction is anathema to much of the party base, but lawmakers also have to deal with other threats from abortion rights opponents in Congress, as well as other spending fights,” our Post colleague Mike DeBonis writes. “Even when Democrats held total control of Washington in 2009 and 2010, the Hyde Amendment persisted.”

Additionally, top abortion rights groups have said they won’t oppose the passage of the spending bill this week, “citing the other advances and the futility of pursuing Hyde repeal with Trump in office and Republicans controlling the Senate,” Mike writes.

—Sen. Bernie Sanders, a 2020 presidential contender who also criticized Biden’s support for Hyde, defended his past votes for Hyde in an interview yesterday on CNN. “Well, look, sometimes in a large bill you have to vote for things you don’t like,” Sanders said. “But I think my record as being literally 100 percent ‘pro-choice’ is absolutely correct.”

OOF: Alabama is one of two states without a law ending parental rights of the father if he is found to have conceived the child by rape or incest. It’s become newly relevant after the state adopted the strictest abortion ban in the country last month.

“Last month, Alabama lawmakers considered a bill that addressed ending parental rights in cases of rape that result in conception, but the legislature removed that language, limiting the law to cases in which people sexually assault their children,” our Post colleague Emily Wax-Thibodeaux reports. “State Sen. Vivian Figures (D) and other lawmakers believed the language that was removed could have excluded boys who were assaulted, because they cannot get pregnant. Figures said she didn’t know Alabama lacked a statute preventing rapists from gaining custody of their offspring, but told The Washington Post that she now plans to introduce a bill in the next legislative session.”

More than half the states that do have laws terminating parental rights in rape cases use  a “clear and convincing evidence” standard, which means the evidence has to be “highly and substantially more likely to be true than not.” Other states require a rape conviction – which some activists argue is too high a standard — and others allow either standard to be used.

OUCH: Missouri’s health department says it’s still in search of answers from the state’s last remaining abortion clinic about why some patients were unaware they remained pregnant after getting what the agency described as “failed surgical abortions,” the Associated Press reports.

The state said Friday it identified “serious concerns, one of those involving the handling of fetal tissue extracted from abortions” from a March inspection of the Planned Parenthood clinic in St. Louis. The Department of Health and Senior Services is investigating Boyce and Bynum Professional Services, which handles the fetal tissue. The focus of the review is “to determine why women remained pregnant after the abortion provider and the laboratory confirmed the presence of fetal parts and tissue in the post-surgical abortion pathological examination,” the state said in a news release.

“The agency declined to provide additional details about allegations that some women remained pregnant after receiving abortions at Planned Parenthood and did not specify how many instances it reviewed, citing the ongoing investigation,” the AP writes. “Planned Parenthood says pregnancies can continue after abortions in extremely rare circumstances.”


—  A group of attorneys general and elected prosecutors from various of states and the District of Columbia have signed a joint statement characterizing recent abortion bans as “unconstitutional” and saying they won’t “prosecute individuals pursuant to these deeply concerning laws.”

“Many of these new enactments are ambiguous or silent as to whom they would hold criminally responsible, leaving open the potential for criminalizing patients, medical professionals, healthcare providers, and possibly others who assist in these medical procedures,” wrote the group.

“As some elected prosecutors have noted, the broad restrictions in the laws passed by these states appear to be unconstitutional under Roe v. Wade. Many of us share those legal views, but our commitment to not prosecute women who obtain abortions and health care professionals who provide treatment is not predicated on these concerns alone,” the letter continued. 

The statement was issued via advocacy group Fair and Just Prosecution. It was signed by attorneys general in 11 states and the District of Columbia, as well as from district attorneys across the country, including some from states where recent abortion bans have been enacted, such as from Jefferson County, Ala.; DeKalb County, Ga.; Fulton County, Ga.; Georgia’s Macon Judicial Circuit and Columbus, Ohio.

— Even as politicians and candidates have divided themselves into clear camps on the issue of abortion, the New York Times’s Nate Cohn reports on how voters appear in survey results to be struggling with their own stance.

The public’s views “bear little resemblance to those of politicians, or even to those of the activists and ideologically consistent voters who post political content to social media,” Nate writes: “Some Americans might not hold strong, stable views about abortion. Different poll questions yield different, sometimes contradictory answers — even from the same respondents in the same poll. Question wording is always a factor in survey research. But the differences here may also reflect that many Americans struggle with the complex moral and ethical issues at stake, even as the political conversation is dominated by voters who have made up their minds.”


— At an Oval Office meeting in late May, the president’s top health and science advisers tried to convince him that cutting government funding for medical research that relies on fetal tissue would disrupt valuable research and lead to a legal battle.

But the president chose to side with his political advisers as well as the vice president, our Post colleagues Amy Goldstein and Josh Dawsey report. “Taking a tough stance on fetal tissue research appealed to Trump, who saw it as a way to burnish his antiabortion credentials for his reelection campaign,” they write. “These internal dynamics … demonstrate the primacy of the 2020 election in shaping policy decisions at the administration’s highest levels.”

“This was the president’s decision,” said spokesman Judd Deere, calling it “another important policy . . . to protect the dignity of human life.”

“The change represents a victory for antiabortion advocates, who immediately lauded the change, and a major disappointment to scientists who say the tissue collected from elective abortions has been instrumental to unlocking the secrets of diseases that range from AIDS to cancers to Zika, as well as to developing vaccines and treatments for illnesses such as Parkinson’s disease,” Amy and Josh write.


— Virginia’s Democratic Gov. Ralph Northam announced he set a July 9 date to call state lawmakers back for a special session to tackle gun-control legislation.

Northam also criticized Republican lawmakers who control the General Assembly for previously batting down gun-control measures in committee without allowing a full-legislature vote, as our Post colleague Gregory S. Schneider reports.

“He said his office will work with lawmakers to introduce measures that would require universal background checks; ban assault weapons, silencers and devices that make guns fire faster; and require that residents report lost or stolen firearms to police,” Gregory adds. “House Speaker Kirk Cox (R-Colonial Heights) said he will propose ways to tighten penalties for violating gun laws, including mandatory minimum sentences for certain crimes. Northam has said he will veto mandatory minimums because he believes they disproportionately affect people of color.”

— Vice President Pence will travel to Montana this week to join Sen. Steve Daines (R-Mont.) at the RiverStone Health Clinic in Billings to meet about the issue of substance abuse in the state.

“I’ve been fighting hard to tackle this growing issue all over our state and I’m very grateful to welcome Vice President Mike Pence to Billings next week to continue this fight,” Daines said in a statement. “Together with the Trump Administration and folks all over Montana, we must win this fight for our great state.”

Daines and Pence will receive a briefing on Wednesday from the High Intensity Drug Trafficking Area Task Force and the Yellowstone Substance Abuse Coalition.

— And here are a few more good reads: 






Coming Up

  • The House Veterans Affairs subcommittee on oversight and investigations holds a hearing on the VA’s police force on Tuesday.
  • The House Veterans Affairs Subcommittee on technology modernization holds a hearing on electronic health record systems at the departments of Veterans Affairs and Defense on Wednesday.
  • The House Ways and Means Committee is scheduled to hold a hearing on universal health coverage on Wednesday.


Joe Bden’s reversal on the Hyde Amendment, explained:


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