OKLAHOMA to be the first true Obamacare innovator?

Now that Paul Ryan has let us in on the secret that Obamacare is the law of the land, what's next? Perhaps the very state innovation the ACA was intended to foster.

The ACA contains a provision allowing states to seek waivers of key parts of the law to try their own reforms, provided they satisfy certain criteria:

Section 1332 of the Affordable Care Act (ACA) permits a state to apply for a State Innovation Waiver to pursue innovative strategies for providing their residents with access to high quality, affordable health insurance while retaining the basic protections of the ACA.

State Innovation Waivers allow states to implement innovative ways to provide access to quality health care that is at least as comprehensive and affordable as would be provided absent the waiver, provides coverage to a comparable number of residents of the state as would be provided coverage absent a waiver, and does not increase the federal deficit.

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This is what Vermont was going to use to pursue state-level single-payer before they abandoned the project.

But now we've got the very first red state eying this option for overhauling the ACA: Oklahoma of all places. They've put together a set of recommendations for what they might seek to do under this option.

And it's certainly ambitious.

In 2018, they want to actually take responsibility for running their own insurance markets. States are the primary regulators and reviewers of insurance products sold in their state. However under the ACA if they declined to do so, the federal government would act in place of the state. CMS is not a state level regulating entity. They applied broad strokes of oversight but they were not familiar with state level policies nor objectives. Oklahoma wants to bring rate review and plan approval back in-house. They don’t need a 1332 for that, but this makes sense.

They also think that they can get improved quality and lower costs by having a coordinated quality metric program. That is ambitious.

The big deal in 2018 that requires a 1332 waiver is changing the age band from 3:1 to no more than 5:1. An actuarial fair age band is probably close to 9:2. This policy change will lower cost plans for young, non-subsidized buyers while hurting non-subsidized older buyers...

2019 is when things get complex. Oklahoma wants to do a lot:

• Move off Healthcare.gov and go to a state based marketplace
• Simplify administrative costs for carriers and change risk adjustment and re-insurance
• Change subsidies from 100-400% FPL to 0% FPL to 300% FPL (this sounds like a back door Medicaid Expansion)
• Use an HSA focused benefit design
• Get rid of metal tiers
• Minimize the required benefit package
• Tighten up eligibility requirements and verification requirements for off-season enrollment

This is a big deal. If implemented, it would be a uniquely Oklahoma solution to Oklahoma problems.

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A key mechanical point that enables every change is moving Oklahoma to their own Exchange in 2019. Healthcare.gov has limited flexibility to support public facing 1332 waivers. A state based marketplace is a key enabling technology. By now, there are enough states with a stable technology platform that Oklahoma can probably buy a system off the shelf and modify it instead of developing from scratch. This will be expensive as an initial investment but not particularly high risk.

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So among the things they want to do is shrink the bronze-silver-gold-platinum plan design to a much simplified two options structure, shorten the 90 day premium grace period to 30 days, fix the family glitch, cover the Medicaid expansion population in the exchange instead of expanding Medicaid, swap the individual mandate for a continuous coverage incentive, explore options for extra subsidies for high-risk cases (ala Maine's "invisible high risk pools" approach perhaps?), put federal subsidy dollars directly into "HSA-like accounts," and take control of their own exchange.

They even connect it to the ACA-funded State Innovation Model award they already got to think through how to reform health care delivery in their state!

I don't love all of it but this is exciting! It's time for states to get serious, take ownership, and make health reform work for them. The war's over, Obama is retired. Let's try some stuff.

Now all they need is for the Trump administration to make shopping across state lines legal.

This may be the way it finally goes together.

chuckiechan said:

Now all they need is for the Trump administration to make shopping across state lines legal.

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They could do that themselves. They just need to do what states like Georgia and Maine have done and allow out-of-state insurers to sell in their markets. The likely reason they're not interested is that those laws had no impact in those states.

Greenbeard said:

They could do that themselves. They just need to do what states like Georgia and Maine have done and allow out-of-state insurers to sell in their markets. The likely reason they're not interested is that those laws had no impact in those states.

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Huh, I live in Oklahoma and this is news to me. Do know given the way our state government has run us into the ground but insists on continuing to pass ignorant laws that get overturned by the courts I can wait to see just how well this attempt works. A state that 'fought' the Real ID act, costing us taxpayers big now that the state has decided to scramble to pass the new ID laws before we Okies need a passport to go on federal property or board a commercial aircraft...

After all, a state government that took a positive state budget and turned it as red as it's voting record, surely can make a YUGE mess of this... eace

Greenbeard said:

They could do that themselves. They just need to do what states like Georgia and Maine have done and allow out-of-state insurers to sell in their markets. The likely reason they're not interested is that those laws had no impact in those states.

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If the insurance company decides to they can, but you as a consumer don't make that choice. The Republicans are saying make all policies available across state lines and available to all consumers.

chuckiechan said:

If the insurance company decides to they can, but you as a consumer don't make that choice. The Republicans are saying make all policies available across state lines and available to all consumers.

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No, they aren't. The GOP has had stock legislative language for its across-state-lines shtick for years (the current Congress is only two months old and that identical language has already been introduced in H.R. 277, H.R. 314, H.R. 1072, and S. 222). It doesn't compel insurers to sell in every state, it simply allows insurers, at their own discretion, to choose to sell in other states without respecting the laws of those states. Insurers hold all the cards under what the GOP proposes.

Greenbeard said:

No, they aren't. The GOP has had stock legislative language for its across-state-lines shtick for years (the current Congress is only two months old and that identical language has already been introduced in H.R. 277, H.R. 314, H.R. 1072, and S. 222). It doesn't compel insurers to sell in every state, it simply allows insurers, at their own discretion, to choose to sell in other states without respecting the laws of those states. Insurers hold all the cards under what the GOP proposes.

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Which is sort of what I said. The ones choosing to sell there are either equal to or higher than existing. I'm talking about low price competitors coming in, uninvited.

As of today, there are no changes.

• Minimize the required benefit package

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any information about what gets minimized here?

Wow, funny how some Red State now not only want to use ACA, but in this case improve it.

Funny how when there was a (D) in the WH the Republicans did all they could to sabotage ACA, and for 7 years use it as a political tool to beat the Dems over the head with. But now? They are working to fix it.

The GOP needs to change their slogan to: 'Party before country'. Because they practice that everyday in every-way.

justabubba said:

any information about what gets minimized here?

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No, they haven't gotten too far into the weeds on that one yet.

Greenbeard said:

Now that Paul Ryan has let us in on the secret that Obamacare is the law of the land, what's next? Perhaps the very state innovation the ACA was intended to foster.

The ACA contains a provision allowing states to seek waivers of key parts of the law to try their own reforms, provided they satisfy certain criteria:



This is what Vermont was going to use to pursue state-level single-payer before they abandoned the project.

But now we've got the very first red state eying this option for overhauling the ACA: Oklahoma of all places. They've put together a set of recommendations for what they might seek to do under this option.

And it's certainly ambitious.




So among the things they want to do is shrink the bronze-silver-gold-platinum plan design to a much simplified two options structure, shorten the 90 day premium grace period to 30 days, fix the family glitch, cover the Medicaid expansion population in the exchange instead of expanding Medicaid, swap the individual mandate for a continuous coverage incentive, explore options for extra subsidies for high-risk cases (ala Maine's "invisible high risk pools" approach perhaps?), put federal subsidy dollars directly into "HSA-like accounts," and take control of their own exchange.

They even connect it to the ACA-funded State Innovation Model award they already got to think through how to reform health care delivery in their state!

I don't love all of it but this is exciting! It's time for states to get serious, take ownership, and make health reform work for them. The war's over, Obama is retired. Let's try some stuff.

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Hey Greenbeard, I am taken aback by your post because I lived in Maine in 2012 and struggled with insurance costs. I NEVER heard of "invisible high risk pools" . With my husband's p.e. condition (cancer), the only insurance we could afford to purchase was from the state provided "Dirigo" health and it was nearly a thousand a month for his insurance alone. If there was some sort of invisible high risk pool option, it was a state secret!