State health coverage innovation and Section 1332 waivers: Implications for states
By Anne Phelps
Deloitte Health Policy Brief
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.
By Don McCanne, M.D.
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.