REGULATORY INTELLIGENCE YEAR-END REPORT - 2022 Health Policy Tracking Service - Issue Briefs Access to Health Insurance Access to Health Insurance This Issue Brief was written by a contributing writer. 12/19/2022 Introduction The ban on surprise medical bills set to take effect January 1, 2022, is expected to lead to lower insurance costs for consumers. The Biden-Harris Administration recently released the Notice of Benefit and Payment Parameters 2023 Proposed Rule, aimed at increasing access to affordable, comprehensive health insurance in 2023. A recent report showed that employer health insurance coverage has been relatively stable during the COVID-19 pandemic, however, the costs of health insurance are greater compared to income than they were ten years ago in every state. Health and Human Services (HHS) Secretary Xavier Becerra and the Centers for Medicare & Medicaid Services (CMS) Administrator Chiquita Brooks-LaSure announced the closing of open enrollment for health insurance plans via the federal marketplace on January 15 and reminded Americans to sign up for coverage. Legislation pending in the 2022 Virginia General Assembly includes two bills that would extend access to health insurance coverage to immigrant children living in the state. The White House released a statement on the enrollment of 14.5 million people in health insurance plans through the federal healthcare exchange, Healthcare.gov, and the state-run health insurance exchanges during the open enrollment period that ran from November 1 through January 15. A bill in Idaho has passed a bill that will provide K-12 teachers access to better health insurance at a lower cost. A group of U.S. Senators wrote a letter to the Department of Health and Human Services (HHS) Secretary Xavier Becerra urging the Biden administration to limit the sale of so-called 'junk plans" for health insurance. Connecticut Governor Ned Lamont announced the introduction of a comprehensive package of legislative proposals aimed at improving health outcomes and reducing healthcare costs for families and small businesses. Millions of people living in California could lose their current health coverage with the expiration of two federal programs that helped them keep coverage during the COVID-19 public health emergency. The U.S. Department of Health and Human Services (HHS) released a new report showing significant gains in health insurance coverage among Black Americans after the implementation of the Affordable Care Act (ACA). The concern has continued over potential loss of health insurance coverage particularly for people covered by government programs as pandemic policies related to continuous enrollment expire. The Biden Administration marked the 12th anniversary of the Affordable Care Act (ACA) by releasing a new report highlighting the gains in access to health insurance due to the federal healthcare reform law. The Biden-Harris Administration recently announced new actions aimed at protecting consumers and helping Americans deal with medical debt. The Ohio House passed a bipartisan bill that will give consumers credit for copay assistance towards out-of-pocket maximums on their health insurance plans. THOMSON REUTERS © 2023 Thomson Reuters. No claim to original U.S. Government Works. According to a recent report by Oregon Health Authority's Health Care Cost Growth Target Program, increasing health care costs led to reduced access to health care for Oregon families and individuals in 2019. The Department of Health and Human Services (HHS), through the Centers for Medicare & Medicaid Services (CMS), announced new measures aimed at assisting consumers in finding quality, affordable health coverage through the federal health insurance exchange, HealthCare.gov. According to a recent report from the Peter G. Peterson Foundation, 28 million people were uninsured in 2020 in the United States when the COVID-19 pandemic began. The U.S. Department of Health and Human Services, through the Office of the Secretary for Planning and Evaluation (ASPE), announced that enrollment in health insurance coverage through government subsidized and facilitated programs was at an all-time high. Friday Health Plans Management Services Company, Inc., ('Friday') a Denver-based health insurance holding company, announced that it had signed an agreement for $70 million of equity investment and $50 million in debt financing that it will use primarily to support expansion into new Affordable Care Act marketplaces. Health insurance costs for people purchasing their own plans are likely to increase next year due to the costs of the COVID-19 pandemic. Washington state submitted a waiver to expand health insurance coverage options to all residents regardless of immigration status. According to a recent survey, the No Surprises Act (NSA) prevented insured consumers from receiving over 2 million surprise medical bills in the first two months of 2022. Health insurers in Minnesota are seeking increases in premium charges for plans available through the individual market in 2023. The United States Department of Health and Human Services (HHS) released a Fact Sheet on the potential effects of the expiration of the enhanced premium subsidies that were temporarily put in place by the American Rescue Plan. Researchers from the Kaiser Family Foundation studied the potential effects of the loss of the enhanced health insurance subsidies. Governor Gretchen Whitmer recently sent letters to all major health insurance companies in Michigan urging them to cover reproductive health care 'to the fullest extent possible under current coverage." The federal government recently implemented rules requiring certain health insurers to publicly disclose rates for in-network and out-of- network medical services. Researchers recently released the results of a study showing that health insurance costs will increase in the coming year due to inflation, the COVID-19 pandemic, and nationwide policy changes. The Centers for Medicare & Medicaid Services (CMS) announced proposals for advancing health equity and improving access to care in rural areas. The Kaiser Family Foundation estimated that 8.2 million health insurance consumers will receive approximately $1 billion in rebates by September 30th from various health insurers. The New York State Department of Financial Services (DFS) announced that it had approved premium rate increases for 2023. President Biden signed the Inflation Reduction Act into law, which included a provision to extend the enhanced subsidies available to eligible consumers purchasing health insurance plans through the ACA marketplace. The census showed that Texas has the highest rate of residents lacking health insurance coverage. The U.S. Department of Homeland Security (DHS) issued a final rule that will help ensure that noncitizens can access health-related benefits and other supplemental government services without negative immigration consequences. New data shows that the number of uninsured people in Nebraska has declined significantly in the two years since the state expanded access to Medicaid coverage. Legislation that would allow community health centers to use federal funding to create new mobile health care delivery sites has passed the United States House and Senate. It will now go to President Biden to be signed into law. The recent survey from the Commonwealth Fund showed that the number of people with health insurance in the United States has increased to a historic high during the COVID-19 pandemic, but that many people still had inadequate coverage. The rate of Americans without health insurance coverage has decreased to historic lows but many people remain uninsured or underinsured. A recent survey by the Kaiser Family Foundation showed that the cost of employer-sponsored health insurance coverage remained similar to costs from last year. THOMSON REUTERS © 2023 Thomson Reuters. No claim to original U.S. Government Works. The U.S. Department of Health and Human Services (HHS), through its Centers for Medicare & Medicaid Services (CMS) announced improvements in access to healthcare including behavioral health services in rural communities. The Biden Administration recently announced a final rule to create a new Medicare special enrollment period for seniors currently enrolled in Medicaid. White House Policies Aim to Increase Access to Health Insurance The Biden-Harris Administration recently released the Notice of Benefit and Payment Parameters 2023 Proposed Rule, aimed at increasing access to affordable, comprehensive health insurance in 2023. The proposed rule is focused on improving shopping for health insurance, creating rules for people to access care, and advancing health equity for consumers purchasing plans through the ACA exchanges. The Centers for Medicare and Medicaid Services announced that the proposed rules follow the Biden-Harris Administration's priority to make coverage more equitable and affordable. 'Today's rule is part of the Biden-Harris Administration's ongoing efforts to ensure an equitable health care system as we continue to make coverage more accessible and affordable," said Health and Human Services Secretary Xavier Becerra. 'We are building a more competitive, transparent and affordable health care market. At the end of the day, health care should be a right for everyone, not a privilege for some." 'This year, we've implemented changes that have helped connect millions of people to health care coverage," said CMS Administrator Chiquita Brooks-LaSure. 'With this proposed rule, we are working to ensure the Marketplaces are a model for accessible, affordable, inclusive coverage-particularly for eligible individuals who have thought comprehensive coverage was out of reach. Under the proposed rule, all insurers offering plans through the federal and state ACA exchanges must provide standardized plan options for all network types, level of insurance, and plan classification and in every service area the insurer offers ACA plans. The standardized plan options will carry a uniform cost-sharing structure. The uniform structure is aimed at facilitating simple and easy to understand comparisons for consumers shopping for plans. According to a report released by the Office of the Assistant Secretary for Planning & Evaluation standardized plans can improve competition and coverage choice for plans available through the exchanges. CMS proposed reestablishing federal network adequacy reviews in states using the federal Marketplace. These reviews would help consumers access the type of provider or facility they need. The reviews would allow consumers to access time and distance to care and appointment wait times. The proposed rule would also increase access to care for people who have low incomes or are medically underserved. Essential community providers (ECPs.) would help with this need. Insurers will be required to include 35 percent of available ECPs in their network for the service area of each plan. Substance Use Disorder Treatment Centers will qualify as eligible ECPs. Health insurance issuers will be explicitly prohibited from discriminating against people because of sexual orientation and gender identity. CMS noted, 'Restoring these protections for covered services-previously removed from the list of non-discrimination protections in 2020-can lead to improved health outcomes in the LGBTQI+ community." The rule proposal also prohibits plans from burdening people with chronic conditions with high prescription costs without a clinical rationale, refining the Essential Health Benefits nondiscrimination policy. Health plan design must be based on clinical evidence. The proposed rule aims to streamline the operation of the ACA exchange and reduce overall healthcare costs through the annual payment notice. Measures include decreasing pre-enrollment verification for special enrollment periods (SEPs). Only the SEP for loss of minimum essential coverage will require verification prior to enrollment. Changes to some individual market plans will lead to lowered premiums for subsidized enrollees beginning in 2023. [FN2] Ban on Surprise Medical Bills Expected to Lower Costs for Consumers The ban on surprise medical bills set to take effect January 1, 2022 is expected to lead to lower insurance costs for consumers. The No Surprises Act passed as part of the coronavirus relief package in 2020 will prohibit surprise medical bills for out-of-network care. Doctors and hospitals that are not covered under a patient's insurance plan will no longer be able to pass along bills to consumers. Health care providers and insurers will be required to work out the cost. Policy experts indicated to Kaiser Health News that the ban in surprise medical bills may slightly slow the increasing cost of health insurance premiums. According to Katie Keith, a research faculty member at the Center on Health Insurance Reforms at Georgetown University, the Biden administration released a rule September 30 that will encourage insurers to pay amounts similar to the costs of in-network care. THOMSON REUTERS © 2023 Thomson Reuters. No claim to original U.S. Government Works. The rule regulates the settlement of network disputes under the new law. Hospital and physician groups opposed the rule. The American Hospital Association, along with the AMA, sued over the aspect of the rule requiring arbitrators to consider certain factors in determining payment amounts. They claim that the provision unfairly benefits insurers. Emergency physicians, radiologists and anesthesiologists filed a similar lawsuit. Under the No Surprises Act, health care providers and air ambulance companies cannot send insured patients large, unexpected balance bills for out-of-network treatment. In the past, even some patients receiving care in in-network facilities received these large bills from out-of-network physicians. Patients were responsible for the difference between what the provider billed and what the insurance company paid. Under the new law, patients will be responsible for only the amount they would have owed for in-network care for the service. Insurers and the out-of-network providers will have to settle any remaining amount. The law allows for 30 days for insurers and providers to work out the payment discrepancies. After the 30-day period, both sides submit their best offer to an arbitrator and the arbitrator picks one. The losing side also pays the arbitration cost of $200 to $500. The law allows uninsured patients to bring a charge to arbitration for a $25 fee if it is more than $400 over an upfront estimate. Approximately 50 businesses will be selected by the three agencies overseeing the program, the departments of Health and Human Services, Labor, and Treasury, as arbitrators. They must show 'expertise in arbitration, health care claims experience, managed care, billing and coding, and health care law.' Parties can object to an arbitrator. A selected arbitrator cannot be associated with an insurer or medical provider. The rule requires the arbitrator to generally choose the amount closest to the median in-network rate negotiated by the insurer for similar care. The arbitrator can consider but not give the same weight to the experience of the provider, the type of hospital or the complexity of the treatment. Over a dozen state laws address surprise medical bills. Some of those laws allow arbitrators to consider higher rates, including the billed charges set by health care providers. Costs could potentially be higher for insurers under those laws. A study in New Jersey showed that cases settled at a median rate of 5.7 times higher than the cost of in-network care. The federal law prohibits arbitrators from considering the highest amounts, billed charges, and the lowest amounts, Medicaid and Medicare, for the services. 'This seems likely to reduce premiums in addition to protecting patients from surprise bills,' said Loren Adler, associate director of the University of Southern California-Brookings Schaeffer Initiative for Health Policy, an author of the New Jersey study. A Congressional Budget Office estimate that provisions in the No Surprises Act could lead to premium growth reductions of 0.5% to 1% annually. Estimates from CMS predict that premiums could slightly increase due to the law. [FNS] CMS Announces Close of Open Enrollment Health and Human Services (HHS) Secretary Xavier Becerra and the Centers for Medicare & Medicaid Services (CMS) Administrator Chiquita Brooks-LaSure announced the closing of open enrollment for health insurance plans via the federal marketplace on January 15 and reminded Americans to sign up for coverage. A new HHS report showed that most consumers enrolled in in coverage through HealthCare.gov have plans with deductibles under $1,000. The lower deductibles are required under the Affordable Care Act (ACA) cost-sharing reductions (CSRs). HHS's Office of the Assistant Secretary for Planning and Evaluation (ASPE) produced the report. Researchers found that CSRs provide significant financial protection to consumers through the marketplace plans. Consumers receive lower deductibles, co-payments, and out-of-pocket maximums. Under the American Rescue Plan (ARP), many consumers qualify for further reductions in deductibles. 'Health coverage should not make or break anyone's bank, particularly amidst a once-in-a-generation pandemic," said Health and Human Services Secretary Xavier Becerra. 'As this report shows, people across America can buy high quality health insurance for historically low prices, thanks to the American Rescue Plan and the Affordable Care Act. The Biden-Harris Administration will continue to build on the success of these important laws to ensure health care is accessible to everyone who needs it. We urge everyone to sign up for affordable health coverage by the January 15 deadline." 'Thanks to the Biden-Harris Administration and the greater financial assistance under the American Rescue Plan, most enrollees now have access to lower cost-sharing in the Marketplaces," said CMS Administrator Chiquita Brooks-LaSure. 'This ASPE report validates the remarkable impact of the ACA and the American Rescue Plan for people who need quality health care coverage. Consumers still have time to take advantage of this financial help by enrolling before January 15." THOMSON REUTERS © 2023 Thomson Reuters. No claim to original U.S. Government Works. According to the ASPE analysis of CMS data from the 2021 Open Enrollment Period (OEP), 51 percent of consumers who enrolled in health insurance coverage through HealthCare.gov during the 2021 OEP received CSRs. Plans at the silver metal tier had average deductibles of $1,000 for HealthCare.gov enrollees in 2017. In 2021, the average deductible for those plans was $750. People are eligible for CSRs if they earn up to 250 percent of the federal poverty level. In most states, that yearly amount in 2022 was $32,200 for a single adult and $66,250 for a family of four. New consumers enrolling during the special enrollment period in 2021, the median deductible decreased from $450 to $50 due to the ARP premium reduction provisions implemented on April 1, 2021. The data indicated that most new enrollees chose silver plans with CSRs. CMS reported that deductibles have been increasing over the past ten years in private health insurance plans. However, over half of enrollees in Marketplace plans receive the CSRs under the ACA, reducing deductibles. Plans with CSRs have decreasing median deductibles yearly. Also, people who have coverage through HealthCare.gov and who qualify for CSRs generally have smaller deductibles than people with employer-sponsored coverage. Employer coverage deductibles averaged over $1,400 in 2021. CMS noted, 'By offering even greater financial assistance to consumers, the ARP has led to a shift towards plan enrollment with lower deductibles." According to the most recent data from CMS, over 14,2 million people chose plans for 2022 health coverage since the beginning of the 2022 OEP on November 1, 2021. Over 10 million people selected plans or were automatically re-enrolled in Marketplace coverage through January 12, 2022 in the 33 states using the federal Marketplace. Seventeen states and the District of Columbia have state-based Marketplaces (SBMs) using their own platforms. They reported that 4.2 million people had selected plans or were automatically re-enrolled for 2022 coverage. Consumers choosing plans during January up until the close of the open enrollment period on January 15 will have coverage beginning on February 1. [FINA] Employer Health Insurance Costs Increase for Employees A recent report showed that employer health insurance coverage has been relatively stable during the COVID-19 pandemic, however, the costs of health insurance are greater compared to income than they were ten years ago in every state. The report, State Trends in Employer Premiums and Deductibles, 201072020, is from the Commonwealth Fund. It is part of an ongoing series examining trends at the state level in the cost of health insurance offered through employers. Researchers found that median incomes have not increased at the same rate as the increase in costs of health insurance and deductibles. Health insurance costs were driven by health care costs and drug costs. The report includes a state-by-state analysis of the cost of health insurance for employees including the cost of premiums, deductibles, and as a share of income. The study included data from 2010 to 2020. According to the researchers, key findings were as follows. In 2020, premium contributions plus deductibles of employer plans equaled 11.6 percent of median income. In 2010, that number was 9.1 percent. In 2020, the average cost of an employee's premium was 6.9 percent of income in 2020. This number represented an increase from the rate in 2010, which was 5.8 percent of income. The average annual deductible for a household considered middle-income in 2020 was 4.7 percent of income. In 2010, the average annual deductible was 3.3 percent of a middle-income household's income. The average total cost of premiums and potential deductibles across both single and family insurance policies provided through employers increased to $8,070. In Hawaii, the lowest average cost of the states, premiums and deductibles were $6,528. In Florida, Kansas, Missouri, South Dakota, and Texas, costs were more than $9,000. Researchers found that an increasing number of states have workers at risk of spending 10 percent or more of their income on health insurance premiums and deductibles. In 2020, workers in 37 states paid an average of 10 percent or more of their income on health insurance costs. In 2010, there were ten states where employees paid 10 percent or more of their income on health insurance coverage and deductibles. In Mississippi and New Mexico, workers with middle incomes have the highest relative cost of health insurance to income at 19% and 18%. THOMSON REUTERS © 2023 Thomson Reuters. No claim to original U.S. Government Works. Almost half of the states have average deductibles for middle-income households that would qualify the households as underinsured and facing high out-of-pocket costs. Only one state in 2010 met this metric. Underinsured includes having a deductible that is 5 percent or more of yearly income. Researchers noted, 'Underinsured people are more likely to struggle to pay medical bills and more likely to skip care because of costs." People in New Mexico faced the highest average deductible relative to median income in 2020 at 7.4 percent. Researchers also found that workers in companies offering lower wages paid more for family premiums than workers in firms paying higher wages. Workers for the lower wage companies paid a larger share of the overall cost of the premium for a family health insurance policy than workers in the higher wage companies. Even though the COVID-19 pandemic led to only about 6 percent of Americans of working age losing employer health insurance coverage, few people became newly uninsured due to the support from the ACA marketplace subsidies and the expansion in eligibility for Medicaid. Researchers indicated, 'However, the financial burden of commercial insurance is an enduring problem that is undermining Americans' economic well-being and causing many to forgo necessary medical treatment." They noted that the passage of the Build Back Better Act would enhance the ACA by significantly increasing the subsidies through the ACA marketplaces, implementing a lower affordability threshold for employer plans, and providing for a no-cost premium marketplace plan option for adults who would be eligible for Medicaid coverage if their states had chosen expansion. [FNS] Idaho Law to Increase Health Insurance Access for Teachers A bill in Idaho has passed a bill that will provide K-12 teachers access to better health insurance at a lower cost. House Bill 443 would create a fund to assist districts and charter schools cover the upfront costs of transitioning onto the state's health insurance plan. Alternatively, the bill will help schools negotiate their own plans with private health insurance companies. In order to fund the changes, the bill would eliminate A $20 million teacher leadership premium program. 'I's kind of bittersweet for me because | was involved in helping create the leadership premium legislation," said former lawmaker Julie VanOrden, R-Pingree, who's substituting for Sen. Steve Bair this session. 'But the money put forward into this insurance bill is a forward-looking piece." The bill passed 32-3 in the senate and received positive reviews from eight bipartisan senators. Some senators, such as David Nelson, D-Moscow, supported the bill as a means to lessen the financial burden of schools for local taxpayers. Taxpayers across Idaho are required to pay supplemental levies. According to Sen. Lori Den Hartog the legislation is a 'historic opportunity" to decrease the cost of health insurance premiums for teachers. 'And | think this will really have a significant impact particularly for our rural districts who have tried to do what they can to pool their resources to try to increase their negotiating power," indicated Den Hartog, R-Meridian. The senators opposing the bill were Republican senators Regina Bayer of Meridian, Christy Zito of Hammett and Steve Vick of Dalton Gardens opposed the bill. None of the legislators debated against the bill. This legislation is the first part of a three-piece proposal by Gov. Brad Little to improve health insurance for school staff. The House easily passed the bill. Separate legislation is pending that would allot $75 million to the new funding amount created by HB443. Sen Jim Woodward, R-Sagle indicated that the spending bill is needed for the health insurance legislation to 'have any significance." Little's third proposal would fund school employee health insurance with $105 million annually. The bill would increase the current $8,400 per school staff state spending on health insurance to the $12,500 amount per person it spends on state employees. Another bill would extend the premiums that veteran teachers receive to a small group of school administrators that were formerly teachers. Currently, only teachers qualify for the state's master educator premium program. Under the current system, awardees must continue working as public-school teachers for three years to become eligible for the three annual $4,000 payments. Some teachers were promoted to administrative positions and did not receive the payments because administrators aren't currently eligible. The new proposal would make them eligible for the payments. The change would be effective retroactively back to the summer of 2020 for the extra payments. [FN6] White House Releases Statement on 14.5 Million Enrollment THOMSON REUTERS © 2023 Thomson Reuters. No claim to original U.S. Government Works. The White House released a statement on the enrollment of 14.5 million people in health insurance plans through the federal healthcare exchange, Healthcare.gov, and the state-run health insurance exchanges during the open enrollment period that ran from November 1 through January 15. President Biden indicated that he was proud to announce the significant enrollment numbers, including over 10 million people who enrolled through the federal platform. Enrollment numbers were the highest ever for an open enrollment period. According to the Centers for Disease Control and Prevention, one in seven uninsured Americans gained coverage between the end of 2020 and September 2021. Americans with lower incomes gained coverage at the highest rate. Biden indicated, 'This did not happen by accident. The American Rescue Plan did more to lower costs and expand access to health care than any action since the passage of the Affordable Care Act. It made quality coverage more affordable than ever-with families saving an average of $2,400 on their annual premiums, and four out of five consumers finding quality coverage for under $10 a month. As a result, millions of our fellow Americans have now gained the security and peace of mind that dependable health insurance brings." The state-run health insurance marketplaces in California, Kentucky, New Jersey, New York, Rhode Island, and Washington, DC remained open for enrollment until January 31. Biden committed to 'keep fighting to lower costs and expand health coverage even more-including through my Build Back Better « [FN7] agenda. Virginia Legislation Would Extend Health Insurance Coverage to Immigrant Children Legislation pending in the 2022 Virginia General Assembly includes two bills that would extend access to health insurance coverage to immigrant children living in the state. Senate Bill 484 and House Bill 1012 would create a program with a focus on allowing all children living in Virginia to access health insurance coverage regardless of immigration status. According to Matt Van de Graaf and Elizabeth Beverly, third-year medical students at Eastern Virginia Medical School, 'It is crucial that Virginia seize this opportunity to cover all kids and brighten the futures of our children and our commonwealth." Van de Graaf and Beverly referenced a patient, a 5-year-old girl, who attends a student-run free clinic for routine pediatric care. They noted that she faces barriers to accessing health care due to her immigration status. They noted, 'Many of the children we see have undocumented immigration status and must come to our free clinic, because they are not eligible for insurance that would cover the health care costs at a pediatrician's office." Children living in Virginia have several means of accessing health insurance, but undocumented children are left out. Approximately 4.9 percent of children in Virginia lack health insurance coverage. That number amounts to around 100,000 children. Undocumented children are disproportionately affected. Almost 50 percent of them are uninsured. Restrictions prohibit them from participating in Medicaid, the Children's Health Insurance Program (CHIP) and the Affordable Care Act marketplace. Van de Graaf and Beverly noted, 'They are our neighbors and will undoubtedly contribute to the continued success of our communities. Yet, they are being excluded from our health care system." They support the pending legislation that would give undocumented children access to coverage, indicating, 'We have the opportunity to uplift every child by creating a state that ensures healthcare for all children. In doing so, we nurture the ideas, talents, and cultures of every Virginian and look to a future that will be brighter for every individual and community in our commonwealth. Let's raise our voices and use our presence to advocate for what's right; let's urge our representatives (you can find yours here) to pass this legislation that supports healthcare coverage and access for every child in Virginia. That's the Virginia we want to call home." According to the Kaiser Family Foundation, 'uninsured children are more likely to lack a usual source of care, to delay care, or to have unmet medical needs than children with insurance." Children without health insurance face worse health outcomes even for common childhood illnesses and preventable hospitalizations. Ten states and Washington, D.C. currently use or have permitted the use of state and district funds to provide access to health insurance coverage to children based on income eligibility regardless of immigration status. In 2021, Virginia passed legislation requiring the Virginia secretary of health and human resources to convene a workgroup to research and recommend strategies to finance health care services for children with undocumented immigration status. [FNS] Connecticut Governor Introduces Health Care Proposals Connecticut Governor Ned Lamont announced the introduction of a comprehensive package of legislative proposals aimed at improving health outcomes and reducing healthcare costs for families and small businesses. 'Healthcare is a human right that too many Connecticut residents struggle to afford," Governor Lamont said. 'Last year, our bipartisan budget created Covered Connecticut to provide nearly 40,000 more people no-cost healthcare through Access Health CT, which is also offering big savings in healthcare for everyone. Although subsidies help, we must also address the high and rising underlying costs of THOMSON REUTERS © 2023 Thomson Reuters. No claim to original U.S. Government Works. care. That's why I'm proposing legislation to make prices more transparent, safely re-import lower-cost prescription drugs from Canada, and cap run-away prices on prescription drugs here at home. Three in ten Americans report cutting pills in half, skipping doses, or swapping out drugs to save money ? with the legislature's help, that stops now." The legislative package is focused on the following goals. Increase price transparency and stabilize healthcare cost growth by codifying cost and quality benchmarks in Governor Lamont's executive order. Reduce prescription drug prices by capping manufacturer's annual price increases. Limits would keep price increases to no greater than inflation plus two percent. The Connecticut Department of Consumer Protection would also oversee a plan to safely import Canadian drugs for cost-savings. Encourage more primary and preventive care through the creation of a primary care spending target. Insurance cards would be required to contain contact information for primary care providers and telehealth services for easier access. Insurance companies would be required to adopt health enhancement programs similar to those programs open to state employees. Decreased premiums and other financial incentives would encourage residents to complete free screenings recommended by the U.S. Preventive Services Taskforce. Expand access to care and address the healthcare worker shortage. Increase rates for adult dental care and family planning services that will expand the Medicaid provider network. Implement two interstate occupational licensing compacts for doctors and psychologists. Increase funding for education and training for nurses and mental health providers. Increase equitable access to care by using race, ethnicity, and language data to identify and address racial and ethnic disparities in access to healthcare and health outcomes. According to Connecticut Social Services Commissioner Dr. Deidre S. Gifford, 'Governor Lamont's healthcare initiatives for this legislative session will mean real differences in the quality of life for many thousands of Connecticut residents. For our HUSKY Health program ? already one of the leading Medicaid and Children's Health Insurance services nationally ? the governor is proposing provider rate enhancements and other improvements to strengthen our networks and promote even better care for children, families, and individuals we serve. Family planning and dental rate increases in this budget will improve equity and access for HUSKY Health members. Advancing key areas like telehealth, primary and preventive care, cost transparency, and care access and equity, among others, will benefit people throughout the state. | look forward to working with the General Assembly in support of the governor's recommendations." Connecticut Insurance Commissioner Andrew N. Mais indicated, 'Governor Lamont's proposal will help increase the quality and availability of health care for all Connecticut residents as we take the necessary steps to address costs and increase affordability. Getting access to health enhancement programs and being able to easily find a primary care practitioner to be your health care home will help consumers stay healthy in the long run by helping prevent avoidable illnesses and treating those that happen as soon as possible." Connecticut Office of Health Strategy Executive Director Victoria Veltri noted, 'The governor knows that healthcare is critical to every resident in the state and to businesses in our state. Making healthcare affordable begins with understanding what drives healthcare spending. Two years ago, Governor Lamont stood with legislative partners and healthcare stakeholders to charge the Office of Health Strategy with establishing targets for per capita healthcare spending growth with an eye toward driving action among all stakeholders to tie healthcare spending growth to a reasonable rate of growth. He also emphasized the critical importance of shoring up the primary care infrastructure of the state by setting a primary care spending target as a share of all medical expenses. Today, Governor Lamont proposes to make this work permanent, cementing our commitment to making healthcare more affordable by making data available and targeting areas for action." Connecticut Chief Workforce Officer Dr. Kelli Vallieres stated, 'Across the country, we're seeing a massive shortage in our healthcare workers, who, right now, are needed more than ever. Governor Lamont's legislative proposals tackle this issue head on by increasing faculty capacity at our colleges and universities so Connecticut can train more students to enter these fields, developing more streamlined pathway programs so we can address this shortage as fast as possible, and making this education more affordable by offering tuition assistance to students, especially those in the hardest hit communities." The Lamont administration pointed to the success of the Creating the Covered Connecticut program. This program gives access to no-cost care to nearly 40,000 adults making too much for Medicaid, but less than 175% of the Federal Poverty Level, through Access Health CT. Connecticut has also prevented increases in health insurance rates that saved consumers a $173 million. The state also helped consumers access healthcare by capping the cost of copays for insulin at $25 per month and for insulin-related supplies at $100 per month. The state required equal health insurance coverage for mental illness and substance use disorder conditions on the level of coverage for other illnesses. THOMSON REUTERS © 2023 Thomson Reuters. No claim to original U.S. Government Works. Under Governor Lamont, Connecticut also expanded HUSKY benefits to families earning less than 160% of the federal poverty level, as well as to qualifying new mothers for a full year after giving birth. [FNS] Senators Urge Biden to Limit Access to Low-Quality Health Insurance Plans A group of U.S. Senators wrote a letter to the Department of Health and Human Services (HHS) Secretary Xavier Becerra urging the Biden administration to limit the sale of so-called 'junk plans" for health insurance. The forty Senators, including U.S. Senators Tom Carper and Chris Coons (both D-Del.) encouraged the administration to limit the sale and availability of short-term, limited-duration insurance (STLDI) plans. The Senators asserted that the plans fail to provide adequate, comprehensive health insurance coverage. Junk plans have been allowed to proliferate since the 2018 decision of the Trump administration to make them more widely available to consumers. The plans are not required to adhere to the standards of the Affordable Care Act (ACA), including prohibitions on discrimination against people with pre-existing conditions, coverage for the 10 essential health benefit (EHB) categories, and annual out-of-pocket maximums. 'It is our responsibility to ensure that all Americans have access to affordable and comprehensive health care coverage. In order to strengthen that commitment, HHS must act quickly to limit the proliferation and promotion of STLDI plans, and undue the sabotage caused by the previous administration,' said the Senators. The Senators pointed to increases in enrollment in ACA compliant plans through the health insurance marketplaces as evidence of improved and expanded access to quality health plans. In Delaware alone, over 32,000 residents enrolled in health insurance coverage during the last open enrollment period, representing a 25% increase from last year. In addition to Senators Carper and Coons, the letter to HHS was also signed by Tammy Baldwin (D-Wis.), Chris Murphy (D-Conn.), Jeanne Shaheen (D-N.H.), Sherrod Brown (D-Ohio), Bob Casey (D-Pa.), Tim Kaine (D-Va.), Michael Bennet (D-Colo.), Richard Blumenthal (D-Conn.), Catherine Cortez Masto (D-Nev.), Tammy Duckworth (D-lll.), Maggie Hassan (D-N.H.), Bob Menendez (D-N.J.), Alex Padilla (D-Calif.), Tina Smith (D-Minn.), Chris Van Hollen (D-Md.), Cory Booker (D-N.J.), Angus King (I-Maine), Ben Ray Lujan (D-N.M.), Elizabeth Warren (D-Mass.), Dianne Feinstein (D-Calif.), Jack Reed (D-R.I.), Patrick Leahy (D-Vt.), Debbie Stabenow (D- Mich.), Gary Peters (D-Mich.), Jacky Rosen (D-Nev.), Jon Tester (D-Mont.), Mark Warner (D-Va.), Raphael Warnock (D-Ga.), Sheldon Whitehouse (D-R.I.), Mazie Hirono (D-Hawaii), Ed Markey (D-Mass.), Ben Cardin (D-Md.), Dick Durbin (D-Ill), Jeff Merkley (D-Ore.), Jon Ossoff (D-Ga.), Charles Schumer (D-N.Y.), John Hickenlooper (D-Colo.), and Bernie Sanders (I-Vt.). In the letter, the Senators indicated, 'We write to . .. encourage you to take additional steps to ensure that even more Americans are protected from substandard plans that do not provide coverage for pre-existing conditions. Now is the time to issue new regulations limiting the sale and availability of short-term, limited-duration insurance (STLDI) plans, also known as 'junk plans' because of their failure to provide adequate coverage." The Senators continued, 'Despite the important gains that we have made in providing comprehensive and affordable coverage for more Americans, STLDI plans continue to sow confusion and cause harm to patients." [FN10} 40 Percent Decline in Uninsured Rate of Black Americans After Affordable Care Act The U.S. Department of Health and Human Services (HHS) released a new report showing significant gains in health insurance coverage among Black Americans after the implementation of the Affordable Care Act (ACA). The report showed historic gains in health care coverage access and affordability among Black Americans. Researchers in HHS's Office of the Assistant Secretary for Planning and Evaluation (ASPE) produced the report. It shows that the uninsured rate among Black Americans under age 65 decreased from 20 percent in 2011, representing about 7.1 million people, to 12 percent in 2019, approximately 4.4 million people. The decline in the uninsured rate was 40 percent. Researchers also pointed to the Biden-Harris Administration's legislative and administrative actions over the past year to expand affordable coverage options through American Rescue Plan subsidies, a Marketplace Special Enrollment Period (SEP), and enhanced outreach to Black Americans. 'As we celebrate Black History Month, we are proud to report historic gains in health care coverage for Black Americans," said Health and Human Services Secretary Xavier Becerra. 'The Biden-Harris Administration is committed to building on the success of the Affordable Care Act and ensuring equitable access to the high-quality, affordable health care that everyone deserves. We will continue to work tirelessly to remove barriers to coverage and double down on our efforts to get more Black Americans insured." 'Since the passage of the Affordable Care Act nearly 12 years ago, the law has significantly expanded access to life-saving health coverage, including for Black communities across the country," said Centers for Medicare & Medicaid Services (CMS) Administrator Chiquita Brooks-LaSure. 'Advancing health equity is one of my top priorities, and, in pursuit of this goal, CMS invested in significant outreach to the Black community during this recent Open Enrollment period. The coverage gains achieved during Open Enrollment THOMSON REUTERS © 2023 Thomson Reuters. No claim to original U.S. Government Works. are just a first step ? CMS will continue to advance health equity by expanding coverage access through Medicaid and the Children's Health Insurance Program, Medicare and the ACA Marketplaces." Researchers found that states choosing not to expand Medicaid have the highest percentage of uninsured Black adults and children. The twelve states that have not expanded Medicaid are Alabama, Florida, Georgia, Kansas, Mississippi, North Carolina, South Carolina, South Dakota, Tennessee, Texas, Wisconsin, and Wyoming. If those states expanded Medicaid, an estimated 957,000 Black Americans without insurance coverage would become eligible for coverage under the program. Researchers pointed to the Special Enrollment Period (SEP) that the Biden-Harris Administration made available due to the COVID-19 public health emergency in order to further expand health care coverage among Americans. The SEP ran from February 15 to August 15, 2021. According to HHS, 'Many of the approximately 30 million uninsured Americans are members of communities of color, and health coverage has been perceived as out of reach because of cost. With increased subsidies from the American Rescue Plan (ARP), 76 percent of uninsured Black Americans could find a plan on Healthcare.gov for less than $50 a month, and 66 percent could find a plan for $0 a month in 2021." In addition, the Biden-Harris Administration also extended the deadline for the 2022 Open Enrollment Period, which ran from November 1, 2021, to January 15, 2022 in most states, to give people more time to sign up for health insurance. More uninsured Americans gained health insurance coverage due to the significant investments in outreach, including quadrupling the number of health assistors, also known as Navigators, who help people sign up for coverage. Many Navigators are trusted within their communities, including Black communities. The Biden-Harris Administration also doubled the size of the Champions for Coverage program. They expanded the targeted outreach for enrollment events in popular places of gathering, including barbershops and salons. The Administration also ran outreach initiatives like the Black American Week of Action and the 'Take Care of Joy" campaign that stressed the importance of protecting the joy in life by protecting your health and the health of your loved ones. Researchers made several key findings: Since the implementation of the ACA's coverage provisions, the uninsured rate among Black Americans under age 65 decreased by 8 percentage points, from 20 percent in 2011 (approximately 7.1 million people) to 12 percent in 2019 (approximately 4.4 million people). The uninsured rate for Black Americans, however, is still higher than that for White Americans: 12 percent compared to 9 percent. The uninsured rate among Black Americans that report Latino ethnicity is similar to the uninsured rate among non-Latino Black Americans. Southern states that have not expanded Medicaid have some of the nation's highest uninsured rates for all population groups, as well as large Black populations. While access to care improved for Black Americans between 2011 and 2020, disparities in affordability of health care between Black and White Americans persist. Beginning in 2021, the Biden-Harris Administration implemented legislative and administrative actions aimed at expanding affordable coverage options. The American Rescue Plan increased subsidies for health insurance premiums available through the Marketplace. Due to the increase, 76 percent of uninsured Black Americans had access to a health insurance plan for less than $50 per month. Sixty-six percent of uninsured Black Americans were eligible for plans in 2021 for $0 a month. During the SEP in 2021, uninsured individuals and current HelathCare.gov enrollees received an opportunity to enroll in affordable coverage or change their plans. To encourage enrollment, the Administration increased funding. Also, it partnered with organizations to increase outreach to uninsured Black Americans and other populations. Researchers found that among SEP enrollees reporting their race and ethnicity, the share of enrollees that were Black increased from 9 percent in 2019 to 15 percent in 2021. FN" Many Californians Could Lose Health Coverage Due to Pandemic Policies Expiring Millions of people living in California could lose their current health coverage with the expiration of two federal programs that helped them keep coverage during the COVID-19 public health emergency. Predictions indicate that 2 to 3 million people living in California could lose their eligibility for Medi-Cal coverage. Coverage losses will begin as early as the summer if the federal government's COVID-19 public health emergency ends. The ending of the federal government public health emergency is scheduled for next month. THOMSON REUTERS © 2023 Thomson Reuters. No claim to original U.S. Government Works. -10- Also, the increased federal subsidies for health insurance plans purchased through Covered California are set to expire at the end of the year. The increased subsidies are available under the American Rescue Plan. The protections created due to the COVID-10 pandemic led to an increase in the number of people in California covered by health insurance. Almost 14.5 million people are currently enrolled in Medi-Cal, which is the highest number ever. Additionally, a record 1.8 million people in the state purchased health insurance through Covered California during the most recent open enrollment period. State health officials are preparing for the expiration of the federal protections, aiming to keep Californians covered. During the pandemic, the yearly renewal requirement for Medi-Cal was frozen. The federal government has prevented states from dropping enrollees from Medicaid. With the expiration of the public health emergency on April 15, the renewal requirement freeze will end. Approximately 2 to 3 million people will be dis-enrolled because they either earn too much to qualify or they fail to provide documentation required for renewal. Advocates are concerned that people losing Medi-Cal coverage will not successfully transition to other types of coverage, leading to an increase in the number of people in California without health insurance coverage. [FN12] Biden Administration Marks 12 Year ACA Anniversary The Biden Administration marked the 12th anniversary of the Affordable Care Act (ACA) by releasing a new report highlighting the gains in access to health insurance due to the federal healthcare reform law. The U.S. Department of Health and Human Services (HHS) released the report, the 'State of the ACA" report, published by the Centers for Medicare & Medicaid Services (CMS). It pointed to the record high enrollment during the 2022 open enrollment period and other key health care coverage gains during the Biden-Harris Administration. CMS indicated that the ACA is the strongest it has ever been and credited President Biden with recent successes. CMS pointed to Biden's investments in health care through the American Rescue Plan (ARP). Throughout the United States, 2.8 million more consumers received tax subsidies from the federal government for the purchase of private health insurance plans in 2022. 'President Biden promised to build on the success of the Affordable Care Act, and just one year into his Administration, we have already broken records with all-time high enrollment numbers and all-time low prices," said HHS Secretary Xavier Becerra. 'We will continue working to deliver on that promise until we make health care a right for all." Almost 6 million new consumers enrolled in coverage through the ACA Marketplaces during the first year of the Biden-Harris Administration. Enrollment happened during the 2021 Special Enrollment Period (SEP) and the Open Enrollment Period (OEP). 2.8 million people enrolled in new plans during the SEP. Over 3 million new enrollees joined during the OEP. The ARP made health insurance plans more affordable for many consumers. A record high 14.5 million people signed up for health insurance plans, representing a 21 percent increase from last year. 'On the 12th Anniversary of the ACA, it is clear that the Affordable Care Act and the American Rescue Plan are working to expand access to health care coverage and have been critical to advancing health equity," said CMS Administrator Chiquita Brooks-LaSure. 'The Biden-Harris Administration's ARP subsidies were successful and ensured that more Marketplace consumers than ever had access to quality, affordable health care and the peace of mind that comes with having health care coverage that best fits their needs." The HHS Office of the Assistant Secretary for Planning and Evaluation (ASPE) published a report showing that more Americans have gained coverage due to the ARP and other administration policies favoring easier access to health insurance coverage. Without increased subsidies available under the ARP, known as Advanced Premium Tax Credits (APTC) for enrollees choosing plans through the HealthCare.gov Marketplace, the average monthly premium would have cost $59 per month more, which would have been a 53 percent increase. A recent ASPE report showed that an estimated 3.4 million Americans with current health insurance coverage in the individual market would lose coverage and become uninsured if the ARP's premium tax credit provisions are not renewed. The rate of uninsured people in the United States decreased after the implementation of the ARP, the 2021, SEP and expanded outreach efforts under the Biden-Harris Administration. The uninsured rate in the United States was 8.9% during the third quarter of 2021. In the last quarter of 2020, the uninsured rate was 10.3%. According to CMS, 'The Biden-Harris Administration has made it a priority to continue to strengthen the ACA. President Biden is committed to building on the progress made by the ACA by reducing premiums for the millions of Americans enrolled in Marketplace coverage and closing the Medicaid coverage gap, which would lead to four million uninsured people gaining coverage. Over 18.7 million adults are now covered across 39 states (including the District of Columbia) due to Medicaid expansion, though 12 states have not expanded. ' THOMSON REUTERS © 2023 Thomson Reuters. No claim to original U.S. Government Works. -11- The Administration also announced a new Special Enrollment Period for low-income consumers. People with household incomes below 150% of the Federal Poverty Level (approximately $19,000 for an individual and $40,000 for a family of four in 2022) qualify. In states using the federal platform, HealthCare.gov, 45% of consumers signing up for health coverage during the 2021 SEP had household incomes under 150% of the Federal Poverty Level. The new SEP is aimed at increasing access to enrollment in Marketplace coverage throughout the year for low-income people. HHS hosted a week-long celebration of the 12-year anniversary of the ACE. It ran from March 21 through March 25. It focused on the impact of the law and the Administration's commitment to continuing its legacy. The theme was 'ACA: 12 Years of Advancing Health Equity for All Americans." HHS spotlighted the gains under the ACA in addressing health disparities of women and families, kids, older adults, people with disabilities, LGBTQI+ and communities of color. [FN13] Concern Over Coverage Loss as Pandemic Policies Set to Expire The concern has continued over potential loss of health insurance coverage particularly for people covered by government programs as pandemic policies related to continuous enrollment expire. The expiration of the policies could begin as early as the summer of 2022. Estimates indicate that approximately 15 million people currently covered by Medicaid could have to find new sources of health insurance coverage or become uninsured. Other pandemic policies expiring could require congressional action to keep telehealth access for Medicare enrollees. Expiring policies could affect special rules and payment policies for health care providers and insurers. Emergency use approvals for COVID-19 treatments could also be affected. The COVID-19 public health emergency was first declared over two years ago. It has been renewed periodically. Currently, it is scheduled to end on April 16. The Biden Administration is expected to extend the transition through mid-July. Some parts of the health care industry would prefer a longer period of transition for the end of policies that could become seriously disruptive. The health care system is complex and relies on private and government insurance and many policies and procedures. 'The flexibilities granted through the public health emergency have helped people stay covered and get access to care, so moving forward the key question is how to build on what has been a success and not lose ground," indicated Juliette Cubanski, a Medicare expert with the nonpartisan Kaiser Family Foundation, who has been researching potential consequences of the end of the public health emergency and related policies and procedures. Medicaid currently covers about 79 million people, a record number of people, in part due to the ongoing COVID-19 pandemic. According to the nonpartisan Urban Institute think tank, approximately 15 million people could lose Medicaid when the public health emergency ends. At least 1 million people per month could lose Medicaid coverage. Due to COVID-19, Congress increased federal Medicaid payments to states. However, it also required states to keep people enrolled in the program. Normally, states kick Medicaid recipients off enrollment regularly when their income levels increase, or they otherwise lose eligibility. This policy will go into effect again when the public health emergency ends. Almost all the people losing Medicaid eligibility are expected to be eligible for coverage through their employers, the ACA Marketplace, or the Children's Health Insurance Program (CHIP). However, enrollment is not automatic for these other sources of health insurance coverage. According to Matthew Buettgens, lead researcher on the Urban Institute study, cost and lack of awareness of eligibility could affect access to coverage. People losing Medicaid eligibility may not be aware of tax subsidies for coverage available through the ACA. If they have coverage available through their employers, the premium cost might be too high. CMS is telling states to move the process slowly and try to connect Medicaid recipients with other potential coverage. 'We are focused making sure we hold on to the gains in coverage we have made under the Biden-Harris administration," said CMS Administrator Chiquita Brooks-LaSure. 'We are at the strongest point in our history and we are going make sure that we hold on to the coverage gains." IFN14] Ohio House Passes Bill to Allow Credit for Copay Assistance The Ohio House passed a bipartisan bill that will give consumers credit for copay assistance towards out-of-pocket maximums on their health insurance plans. The bill was passed without opposition, 89-0. THOMSON REUTERS © 2023 Thomson Reuters. No claim to original U.S. Government Works. -12- It will eliminate a practice of copay accumulator. Health insurers do not give consumers credit toward out-of-pocket costs annual maximums if consumers receive copay assistance from drugmakers, churches, nonprofits or family members. House Bill 135 passed the House Health Committee unanimously in March 2021. However, it was delayed from being brought to the House floor until recently because of opposition from health insurers and pharmacy benefit managers. Twelve other states and Puerto Rico already have laws in place preventing health insurers from manipulating copays and demanding more payment from consumers. Fifteen additional states have legislation pending. Nine out of ten current insurers offering health insurance plans through the Affordable Care Act exchange in Ohio have accumulator programs that prevent consumers from benefitting from co-pay assistance. The bill will now go to the Ohio Senate for approval. According to Representative Manchester, Hb135 would 'remove discriminatory administrative practices that negatively impact consumers trying to beat their mandated health insurance cost-sharing practices.' The legislation 'is needed to assist our constituents who find themselves increasingly subjected to more out-of-pocket costs as part of their insurance coverage.' Ohio state Rep. Thomas West, D Canton, speaking at an Ohio Promise rally noted that the proposal 'a patient friendly bill at its very core.' His platform for election was lowering the cost of prescription medications. Rep. Bill Seitz, a GOP leader from the Cincinnati area delayed the bill for over a year. He eventually agreed to an amendment of the bill. 'So there were some differences that we had to work through, and even some clarifications that needed to be made,' Manchester said. 'Look, at the end of the day we were able to come together and come around this bill.' Manchester was hopeful that the Senate would approve the bill, particularly after it received unanimous passage in the House. Manchester stated, 'We want to make sure that patients continue to have access to their medications and that ultimately can access them at the lowest cost possible.' [FN15] White House Announces Plan to Address Medical Debt The Biden-Harris Administration recently announced new actions aimed at protecting consumers and helping Americans deal with medical debt. According to the White House, the actions will help: Hold medical providers and debt collectors accountable for harmful practices; Reduce the role that medical debt plays in determining whether Americans can access credit ? which will open up new opportunities for people with medical debt to buy a home or get a small business loan; Help over half a million of low-income American veterans get their medical debt forgiven; and, Inform consumers of their rights. Medical debt affects one in every three adults in the United States. It is currently the largest source of debt in collections, even larger than credit card, utility, and auto loan debt combined. Black and Hispanic households are more likely to have medical debt than white families. Medical debt can also prevent people from seeking needed medical care. A study showed that one-half of all people with medical debt avoid seeking care. The White House noted, 'Getting sick or taking care of loved ones should not mean financial hardship for American families. That is why the Administration is taking new action to ease the burden of medical debt and protect consumers from predatory collection policies. These actions build upon the President's April 5th Executive Order on strengthening access to affordable, quality health care coverage, which directed federal agencies to take action to reduce the burden of medical debt." Vice President Harris announced reforms in four significant areas focused on helping people with the burden of medical debt, protecting consumers, and creating new opportunities for Americans to purchase a home or start a small business. Part of the plan will aim to hold providers and collectors accountable for activities related to debt collection of medical debts. Families facing medical debt, often due to being uninsured or underinsured, providers have a responsibility to offer payment plans or financial assistance that are non-predatory. Many providers offer appropriate payment plans. However, many eligible patients indicated that they have not received assistance. Also, lawsuits against patients over medical bills are increasing. Providers can sell bills to third party debt collectors. Many of these debt collectors pursue aggressive collections practices. THOMSON REUTERS © 2023 Thomson Reuters. No claim to original U.S. Government Works. -13- The White House pointed to the federal government's contribution of roughly $1.5 trillion per year into the health care system. Providers receiving funding from the federal government should be held to a higher standard, making it easier for consumers to access financial assistance. Secretary Becerra is directing the Department of Health and Human Services (HHS) to look at billing practices of providers and how those practices relate to accessibility and affordability of care and the accrual of medical debt. HHS will require over 2,000 providers to submit data on medical bill collection practices, lawsuits filed against patients, financial assistance, financial product offerings, and 3rd party contracting or debt buying practices. The Department will use this information to make grantmaking decisions, publish topline data and policy recommendations for the public. It will also share potential violations with enforcement agencies. Additionally, the Consumer Financial Protection Bureau (CFPB) will investigate credit reporting companies and debt collectors that violate patients' and families' rights. Violators will be held accountable. The CFPB has already warned debt collectors through a bulletin about unlawful medical debt collection and reporting practices. The agency will now work on targeting coercive credit reporting and determine if unpaid medical billing data should be included in consumers' credit reports. According to recent research, owing medical debt is not a reliable predictor of overall financial health. Researchers looked at 5 million anonymized credit records. They found that consumers who owed medical debt paid their bills at the same rate of those who did not have medical debt. Including paid-off medical debt causes credit scores to underestimate creditworthiness by a significant amount, up to 22 points. 'As a result, the inclusion of medical debt on credit reports and in credit scores and loan underwriting can hold American's back from financial opportunities while failing to improve the accuracy and predictiveness of lending programs," the White House indicated. Last month, three of the largest credit reporting agencies, including Equifax, Experian, and Transunion announced that they would no longer include some forms of medical debt on credit reports. This action removed billions of dollars of medical debt from consumer reports. The change will apply to consumers with medical debts that have already been paid, unpaid debts of less than one year old, and debts paid or unpaid under $500. [FN16] HHS Announces Measures to Improve Access to Health Insurance The Department of Health and Human Services (HHS), through the Centers for Medicare & Medicaid Services (CMS), announced new measures aimed at assisting consumers in finding quality, affordable health coverage through the federal health insurance exchange, HealthCare.gov. The measures were announced in anticipation of the Open Enrollment Period beginning later this year on November 1. They are part of the Biden-Harris Administration's efforts to build on the Affordable Care Act (ACA). 'The Affordable Care Act has successfully expanded coverage and provided hundreds of health plans for consumers to choose from," said Health and Human Services Secretary Xavier Becerra. 'By including new standardized plan options on HealthCare.gov, we are making it even easier for consumers to compare quality and value across health care plans. The Biden-Harris Administration will continue to ensure coverage is more accessible to every American by building a more competitive, transparent, and affordable health care market." 'The recent Open Enrollment Period demonstrated the demand for high-quality, affordable health coverage. These steps increase the value of health care coverage on HealthCare.Gov and further strengthen the health insurance Marketplace," said CMS Administrator Chiquita Brooks-LaSure. 'This policy will make it easier for people to choose the best plan that meets their needs by standardizing plan options, like maximum out-of-pocket limitations, deductibles, and cost-sharing features." The changes were announced in the 2023 Notice of Benefits and Payment Parameters Final Rule (final 2023 Payment Notice). The regulation makes changes in the individual and small group health insurance markets. It also creates parameters and requirements for insurers. Regulations target the design of plans and the rate of premiums for the 2023 plan year. The rule also provides regulatory standards to states, the Marketplaces, and health insurance companies serving the individual and small group markets. One major change is aimed at advancing standardized plan options. The rule follows President Biden's Executive Order 14036 on Promoting Competition in the American Economy. It focuses on a simpler consumer shopping experience. It creates standardized plan options for issuers offering Qualified Health Plans (QHPs) on HealthCare.gov. Consumers will benefit from standardized maximum out-of-pocket limitations, deductibles, and cost-sharing features from multiple plans. It will be easier to compare other important plan attributes, including premiums, provider networks, prescription drug coverage, and quality ratings. THOMSON REUTERS © 2023 Thomson Reuters. No claim to original U.S. Government Works. -14- The standardized plan options will allow consumers to access coverage for important medical services before meeting deductibles. The simplified cost-sharing structures will make it easier for consumers to understand coverage. Insurers who offer QHPs on HealthCare.gov will have to offer standardized plan options for each network type and at every coverage level from Bronze through Platinum. These requirements will span every service area where non-standardized options are offered beginning in 2023. The HealthCare.gov website will display these plans in a manner aimed at assisting consumers in making informed choices about health insurance plans. The regulation will also require new network adequacy standards. The rule will help improve access to care by increasing coverage of providers and locations. QHPs on the Federally-facilitated Marketplace (FFM) will have to cover certain classes of providers withing time and distance parameters. For example, provider networks must include primary care providers within ten minutes and five miles of enrollees in large metro areas. Beginning in the 2024 plan year, QHPs on HealthCare.gov must ensure that covered providers meet minimum appointment wait time standards. Routine primary care appointments must be available within 15 business days of an enrollee's request. HHS will review standards for minimum appointment wait times and distances for specialist providers. Provider networks for emergency medicine, outpatient clinical behavioral health, pediatric primary care, and urgent care as well as OB/ GYN care will have to meet certain time and distance standards. CMS will also update the permitted range in metal coverage levels for non-grandfathered individual and small group market plans. The change will require some plans to increase coverage and make it more comprehensive. The costs will be lower for many consumers purchasing ACA plans. The changes will also facilitate comparison of coverage from the metal level plans, Bronze, Silver, Gold, and Platinum. The regulation also increases standards to prevent discrimination based on age and health conditions for the coverage of essential health benefits (EHB). The protected categories must be clinically-based to be considered nondiscriminatory. The regulation updates Quality Improvement Strategy Standards to require issuers to address health and health care disparities. The rule will also expand access to Essential Community Providers (ECP) by increasing the threshold from 20% to 35% of available ECPs in a plan's service area. The increased percentage of providers must be included in a plan's provider network. The change will increase access to providers for low-income and medically underserved consumers with ACA plans. The change should not be too taxing to achieve, in P2021, 80% of QHPs on the FFM had already met the standard. The FFM and State-based Marketplaces on the Federal Platform (SBM-FPs) user fees for 2023 will remain at the same level as 2022. The fees will ensure adequate funding for the functioning of the federal Marketplace, including consumer outreach efforts and education, determination of eligibility, and enrollment process activities. [FN17] Report: Healthcare Costs Reduce Access in Oregon According to a recent report by Oregon Health Authority's Health Care Cost Growth Target Program, increasing health care costs led to reduced access to health care for Oregon families and individuals in 2019. Researchers found that the average costs of health care reached over 23% of family expenses. Personal spending for health care increased by 34% from 2013 to 2019, a larger increase than national averages. Annual costs of premiums neared $20,000 per family, making financial instability and inequities worse. The cost of health care including premiums and out-of-pocket costs led to financial instability for many Oregon residents. Ten percent of state residents reported using all or most of their savings on medical bills. 'This report fleshes out with data a troubling picture of the impacts of rising health care costs on Oregon families," said Jeremy Vandehey, director of the Health Policy and Analytics division of the Oregon Health Authority. 'While we've known for a long while that the rate of cost growth was unsustainable, COVID showed us in stark relief how important access to affordable care was to Oregon families. High costs not only cause poor health outcomes, but they also do real financial harm to people in Oregon. The data in this report reinforces the need in our state for our cost growth target, which aims to limit annual increases in health care costs statewide to 3.4% over the next several years. And even as the pandemic destabilized so many things, we still know Oregon families cannot sustain further health care cost burdens." Researchers found that the high cost of insurance premiums and medical care led to people delaying care, having trouble paying medical bills within the past year, having difficulty paying off medical bills over time, using all savings to pay for medical bills, incurring debt, and declaring bankruptcy. THOMSON REUTERS © 2023 Thomson Reuters. No claim to original U.S. Government Works. -15- The Cost Growth Target Committee held a hearing to bring the voices of people struggling with the cost of medical care to light. Testimony showed the impact of high medical costs on quality of life. A small business owner testified that they have a high deductible health plan that costs $500 per month and covers nothing until the $8,000 per year deductible is met. They pay for all medical care out of pocket through their Health Savings Account and go without medical care because of the expense. The cost of commercial health insurance premiums has increased by 22 percent from 2013 to 2019 for individual and family health plans. The average family premium in 2019 was $19,405. The average single premium was $6,651. [FN18] HHS Announces All-Time High Enrollment The U.S. Department of Health and Human Services, through the Office of the Secretary for Planning and Evaluation (ASPE), announced that enrollment in health insurance coverage through government subsidized and facilitated programs was at an all-time high. ASPE released a report showing new estimates for coverage related to the Affordable Care Act (ACA). Researchers found that the total enrollment for Medicaid expansion, Marketplace coverage, and the Basic Health Program in participating states has reached an all-time high of more than 35 million people as of early 2022. The Centers for Medicare & Medicaid Services (CMS) recently released a report showing all-time high of 21 million people in more than 40 states and territories gained health care coverage. The gains were credited to the expansion of Medicaid coverage under the ACA to low-income adults under 65. Medicaid expansion in states that occurred during the Biden-Harris Administration led to gains in coverage for over two million people throughout the United States. The increases benefitted underserved communities during the COVID-19 pandemic. According to the ASPE report, new estimates from the National Health Interview Survey indicated that the uninsured rate in the fourth quarter of 2021 was at nearly an all-time low of 8.8% for the full population. In the third quarter of 2021, the rate was 8.9%. During the fourth quarter of 2020, it was 10.3%. 'With a record-breaking total of over 35 million people who now have health coverage, thanks to the Affordable Care Act, America's uninsured rate is nearing an all-time low," said Health and Human Services Secretary Xavier Becerra. 'Today's historic reports show we are delivering on our commitment to bring health care coverage to as many people as possible. We will continue to push for comprehensive ACA coverage and Medicaid expansion and work with states to make comprehensive health care accessible and equitable for families across the country." HHS pointed to the gains in coverage through Medicaid expansion as 'a path to affordable, comprehensive, person-centered care" for people living in the 12 states that have not yet expanded access to Medicaid coverage. Those states include Alabama, Florida, Georgia, Kansas, Mississippi, North Carolina, South Carolina, South Dakota, Tennessee, Texas, Wisconsin, and Wyoming. If the remaining states choose to expand Medicaid eligibility, it would significantly advance health equity. Nearly four million people would gain coverage. Over half of them are people of color. In 2021, Oklahoma and Missouri expanded Medicaid, leading to enrollment increases of over 276,300 and 146,600 people in those states. 'Medicaid is a lifeline to better health and care for millions of people-including the millions who gained coverage thanks to expansion under the Affordable Care Act," said CMS Administrator Chiquita Brooks-LaSure. 'Medicaid expansion is key to improving maternal and infant health outcomes, addressing longstanding health disparities, and connecting people to needed essential care. Nearly four million additional people could benefit from this coverage if Medicaid is expanded in all states. We can't leave them behind." Medicaid expansion affects people with incomes up to 133% of the federal poverty level, under the changes made by the ACA. People making up to $17,130 for a single person in 2021 and up to $35,245 for a family of four qualified for health insurance coverage in states that expanded Medicaid. The ACA became law in 2010. Since that time, 38 states, the District of Columbia, and three U.S. territories have expanded Medicaid coverage to low-income adults. As a result, over 21 million people gained Medicaid coverage. 'We remain committed to ensuring people have access to quality, affordable, comprehensive, and person-centered health care coverage and the peace of mind that comes with it," said Dan Tsai, CMS Deputy Administrator and Director of Center for Medicaid & Children's Health Insurance Program (CHIP) Services. More than half of the total adults covered under Medicaid are women. Expansion helps to narrow essential coverage gaps for this group. HHS also pointed to current efforts to extend Medicaid and CHIP coverage for a full year after pregnancy. [FN19} 28 Million Without Health Insurance During First Year of COVID-19 Pandemic According to a recent report from the Peter G. Peterson Foundation, 28 million people were uninsured in 2020 in the United States when the COVID-19 pandemic began. THOMSON REUTERS © 2023 Thomson Reuters. No claim to original U.S. Government Works. -16- This number represented 8.6 percent of the population. Researchers collected data from a report from the Census Bureau. Researchers noted, 'While this represents a significant portion of the population without coverage during a major public health crisis, overall the share of people without health insurance has been relatively stable over the past several years." They summarized the most recent data to explore the reasons Americans lacked health insurance coverage, where Americans obtain coverage, and how coverage differs based on demographic factors and age. They also considered how the data has changed over time and how federally subsidized health insurance programs like Medicaid affect uninsurance rates. They also asserted that, 'The pandemic had no significant effect on the share of people without health insurance coverage." In the ten years leading up to the creation and implementation of the Affordable Care Act (ACA) in 2010, the rate of people without health insurance coverage in the United States averaged 15 percent. By the time the provisions of the ACA went into effect, 2014, states were permitted to expand eligibility for Medicaid to low-income adults without children and to create or participate in health insurance marketplaces. The effect of the changes varied by state. Overall, the changes assisted with a 3 percent decrease in uninsured people in the first year. By the middle of the decade, more states had decided to expand Medicaid, leading to a continuing decline in the number of people without health insurance coverage. In the mid-2010s, the uninsurance rate fell below ten percent and has not increased above that level. According to Census data, the uninsured rate in 2020 did not vary meaningfully from the rate in 2018. Researchers pointed to several reasons for the lack of a significant change in uninsured rates. Many people who lost employment during the early part of the pandemic were in low-income jobs and did not have employer-based health insurance. Many people who were laid off became eligible for health insurance coverage through Medicaid or CHIP. People already insured through those programs were less likely to lose that insurance coverage due to the provisions in the Families First Coronavirus Response Act requiring states to ensure continuous enrollment. Since the beginning of the pandemic, enrollment in Medicaid and CHIP has increased by 20 percent. National Health Interview Survey (NHIS) reports similar numbers of people who lost health insurance coverage due to the pandemic. The agency estimated that the highest quarterly uninsured rate of 2020 reached 10.3 percent between October and December. In 2021, that increase in uninsured people reversed when it decreased to 8.9 percent of the total population in the United States. In 2018, the NHIS measure of the uninsured rate was 9.4 percent. According to researchers, 'The Census report also provides significant insights about the state of healthcare access in America during the midst of the pandemic. Health insurance is provided through various sources in both the private and public sectors." Most people had private health insurance coverage in 2020. This coverage includes employment-based insurance plans and plans consumers purchase directly from the marketplace. Private insurance also includes TRICARE serving military members. Public Insurance includes Medicare, Medicaid, the Children's Health Insurance Program (CHIP), and veterans' health programs. Almost twice as many people living in the United States received health insurance coverage through private insurance than through government programs. In 2020, 217 million people were enrolled in private health insurance plans. In the same year, 113 million people were covered under a public program. Some of those estimates overlap because some people had private insurance for part of the year and public insurance for part of the year. [FN20] No Surprises Act Prevented Over 2 Million Surprise Bills According to a recent survey, the No Surprises Act (NSA) prevented insured consumers from receiving over 2 million surprise medical bills in the first two months of 2022. AHIP and Blue Cross Blue Shield Association (BCBSA) conducted the survey and analysis of the data. Researchers predicted that if the trend continues, commercially insured patients will avoid over 12 million surprise bills in 2022. 'The No Surprises Act ended the practice of surprise medical billing in most circumstances, providing relief for millions of patients who faced surprise medical bills they did not expect at prices they could not afford," said Matt Eyles, AHIP president and CEO. 'Health insurance providers applaud the Administration and Congress for taking this important step. But more work needs to be done to ensure a broken bone doesn't break the bank." The NSA includes a provision establishing a process for resolving disagreements over what health plan pays for out-of-network medical services to providers and facilities. The process ends in independent dispute resolution (IDR). The law was implemented in the beginning of 2022. Federal policymakers have had a keen interest in determining how many claims might be disputed through IDR each year and the affect the process will have on affordability of health care. THOMSON REUTERS © 2023 Thomson Reuters. No claim to original U.S. Government Works. -17- Researchers focused their efforts on determining how many patients and consumers have benefited from the law and how important the IDR process will be in predicting overall healthcare costs. 'There is no room for surprise medical bills in a health care system that puts people first," Kim Keck, BCBSA president and CEO. 'As recently as last year, an emergency visit to the hospital may have left patients on the hook for steep, surprise medical bills. The No Surprises Act has not only put an end to this loophole, but it has provided undeniable financial protection to millions of Americans." A recent poll showed voter support for protections against surprise medical bills as well. A poll by Morning Consult on behalf of the Coalition Against Surprise Medical Billing (CASMB) found that 79% of voters are concerned that healthcare providers could delay or overturn the patient protections included in the NSA. [FN21] Washington Files Waiver to Offer Health Insurance Coverage to Undocumented Immigrants Washington state submitted a waiver to expand health insurance coverage options to all residents regardless of immigration status. The Section 1332 Waiver Application filed with the federal government is an effort to expand health coverage options for Washington residents. The state applied for the waiver on May 13. If the federal government approves the waiver, Washington residents, including undocumented immigrants, will be permitted to enroll in health insurance plans and dental coverage through the state health insurance marketplace, Washington Healthplanfinder. Coverage under the waiver would be available beginning in 2024 to Washington residents who are newly eligible. [FN22] Maryland: Health Insurance Costs Likely to Increase Due to COVID-19 Health insurance costs for people purchasing their own plans are likely to increase next year due to the costs of the COVID-19 pandemic. Three carriers offering policies through Maryland's health insurance exchange or directly to consumers living in the state asked for rate increases from state insurance regulators average 11%. 'It is clear from our ongoing monitoring of industry experience that 2021 claims were heavily influenced by COVID-19, and that the significant differences between where we were in 2021 and where we are likely to be in 2023 must be modeled and taken into account in rate development," indicated Kathleen Birrane, the state's insurance commissioner, in a statement. The Maryland Insurance Administration will set rates if September for the insurance after reviewing the request to increase prices. Over 222,000 individuals purchased health insurance coverage through the Maryland health insurance exchange in 2022. Almost 80% of those people qualified for federal tax subsidies to cover all or part of the cost of the health insurance premiums. Most people purchasing their own health insurance plans through the Maryland exchange are not offered health insurance plans by their employers. While tens of thousands of Maryland residents signed up for coverage through the Maryland health insurance marketplace during the special enrollment period opened during the first year of the pandemic, more people became eligible for and enrolled in health insurance coverage under Medicaid. Medicaid enrollment is expected to decrease after states, including Maryland, resume requirements that enrollees periodically verify their eligibility for the program. This requirement was paused temporarily in response to the COVID-19 pandemic. It is set to resume this year. The increased federal subsidies for the purchase of health insurance plans through the Affordable Care Act marketplaces will end by the close of 2022 if Congress does not act to extend the subsidy increases. Most people obtaining health insurance with federal subsidies will retain at least some federal aid toward their monthly premiums. Approximately 1.2 million Maryland residents are enrolled in income-based Medicaid plans. Approximately 175,000 are enrolled in individual private plans through the Maryland health insurance exchange. According to state regulators, they will consider increases to costs in healthcare due to the COVID-19 pandemic as well as enrollment numbers when they consider the new rates. They will also take the actual impact of the pandemic on costs into account. 'Obtaining more detailed information on how COVID-19 claims experience has influenced cost and trend models for 2023 will be the primary focus for our actuarial team," Birrane said. The state's dominant carrier, CareFirst BlueCross BlueShield, requested an average 11.2% rate increase in its HMO plan. The plan currently covers over 149,000 people. The average cost of a silver plan is $353. The requested increase would be an extra $30 per month. CareFirst's PPO plan covers almost 16,300 people. The company requested a 25.9% rate increase for this plan. United Healthcare asked for an average 8.7% increase for its HMO plan. The monthly cost of a silver plan would increase by $28 to $363. [FN23] THOMSON REUTERS © 2023 Thomson Reuters. No claim to original U.S. Government Works. -18- Company Announces Equity Investment for Enrollment Efforts Friday Health Plans Management Services Company, Inc., ('Friday') a Denver-based health insurance holding company, announced that it had signed an agreement for $70 million of equity investment and $50 million in debt financing that it will use primarily to support expansion into new Affordable Care Act marketplaces. Friday had a 400% membership growth year over year for the last two years. 'More people are finding value in our simple, practical health plans designed for people who don't get insurance through their employer,' said CEO of Friday Health Plans, Sal Gentile. 'We are built specifically to give them great health benefits and superior service ? all at an affordable price. And we're able to do this because we focus solely on serving this growing consumer segment.' The company currently has enrollment of over 330,000 members across seven states. Gross premium revenue for 2022 was an estimated $1.95 billion. Most health plans offered by the company include unlimited $0 primary care visits, $0 mental health counseling, free generic drugs and free telehealth visits. Plans are available through the national or state-based health exchanges, through brokers, or directly on the company's website. 'Having worked with the management team at Friday for a number of years, we have observed their expertise in bringing affordable health protection to a growing number of people. We are excited about supporting the future growth prospects of the company through this capital round,' said Tom Spreutels, Managing Partner at Leadenhall. FN24] HHS Releases Fact Sheet on Effects of Enhanced Premium Subsidies The United States Department of Health and Human Services (HHS) released a Fact Sheet on the potential effects of the expiration of the enhanced premium subsidies that were temporarily put in place by the American Rescue Plan. The enhanced subsidies were meant to address the cost of health care and to expand access to affordable and comprehensive health insurance coverage, particularly during the COVID-19 pandemic. According to the Fact Sheet, the enhanced subsidies helped to lower the cost of health insurance by: -Providing additional help with premiums for nearly 90 percent of the 14.5 million consumers that signed up for health coverage on the Health Insurance Marketplaces during the 2022 Open Enrollment Period. -Making help available, for the first time, to individuals with incomes around $52,000 and $106,000 for a family of four. The Biden Administration credited the American Rescue Plan subsidies with leading to record-breaking enrollment in health insurance coverage of 14.5 million people through the federal Marketplace (HealthCare.gov) and state-based health insurance exchanges during the last open enrollment period. Over ninety percent of people signing up for coverage through HealthCare.gov received federal tax subsidies to help pay for the cost of premiums. Four out of five people found plans that cost less than $10 per month through the federal Marketplace. In addition, families saved an average of $67 per person per month on premiums in 2021. HHS warned that premiums will 'skyrocket' of Congress fails to act to extend the American Rescue Plan subsidies. The enhanced premiums are set to expire at the end of the year without an extension. As a result of the enhanced subsidies expiring, HHS predicts that: -Many Health Insurance Marketplace consumers across the country ? in rural and urban areas ? will likely see substantial increases in out-of-pocket premium costs -The number of uninsured Americans will increase significantly -Approximately 3 million Americans could lose their health insurance -More than 10 million Americans will have reduced premium tax credits or lose them entirely: 8.9 million people will have their tax credits reduced (averaging $406 per person, annually) 1.5 million people will lose subsidies entirely (averaging $3,277 per person, annually). [FN25] Minnesota Insurers Seek Increase in Premium Costs Health insurers in Minnesota are seeking increases in premium charges for plans available through the individual market in 2023. Three of the largest health plans in the individual market in the state are seeking the increases. However, the increases are less than what the insurers asked to increase prices for 2022 plans. The price increases would affect the 160,000 people in Minnesota who purchase individual health insurance plans through the state's health insurance exchange. The Minnesota Department of Commerce recently released the rate increase proposals. THOMSON REUTERS © 2023 Thomson Reuters. No claim to original U.S. Government Works. -19- Three large carriers asked for average increases of between 2 and 6%. One large insurer proposed lowering the cost of its premiums by an average of 2%. '| would consider those increases to be moderate,' said Cynthia Cox, a researcher with the California-based Kaiser Family Foundation. The state's department of insurance has not yet approved or finalized the rate increases. The requested rate changes are less than the 10% increases insurers requested a year ago in Minnesota. Even so, the rate increases will affect consumers, especially if Congress fails to act to extend the enhanced federal subsidies that are available now under the American Rescue Plan. According to MNsure, Minnesota's health insurance exchange, approximately 70,000 people will pay more for health insurance premiums without an extension of the enhanced federal subsidies. A trade group for Minnesota's nonprofit health insurers pointed to a state-funded reinsurance program as assisting in keeping premium costs lower for consumers. 'The modest increases in rates reflect a market that is stabilizing and incorporating medical cost increases,' the Minnesota Council of Health Plans stated. Cox indicated that premium trends are different through the United States. Consumers in other states might see larger increases in the cost of health insurance premiums next year than Minnesota residents. Over the past several years, health insurance premium costs have increased more quickly than prices in the rest of the economy. However, with the spike in overall inflation this year, health insurance premium costs are generally increasing at a lower rate compared to prices for other goods and services. Researchers from the Kaiser Family Foundation found that overall prices in April were up 8.3% compared to the previous year. Prices for medical care increased by only 3.2% during the same time. Cox noted that the slower increase in health insurance prices could be due to the slower cost cycle-payments for health services are usually negotiated annually. Cox said, 'Nationally, I'm expecting premiums to increase more than in recent years. Insurers aren't as profitable as they had been in the last few years and we might start seeing inflation in the rest of the economy flow through to the health sector." Consumers in Minnesota can file public comments regarding the rate increases until July 18. The state will release the final numbers before Oct. 1. The largest group of people who purchase health insurance in Minnesota are under 65 and self-employed or do not access health insurance through their employers. The insurers asking for rate increases in Minnesota for 2023 are: UCare 6.2%; Medica 6%; and HealthPariners 2.1%. The HMO at Blue Cross and Blue Shield of Minnesota is seeking a 2.3% decrease. The Minnesota Commerce Department reviewed rate increase proposals last year for 2022 plans. The review process led to three of the largest carriers in the state increasing plans by 1 or 2 percent less than they originally proposed. Another large carrier ended up increasing rates by 4 percent more than originally proposed after the review process for 2022 plans. According to the agency in background materials it released about the 2023 proposals, 'The Commerce Department does not 'set' health insurance rates." 'Instead, it reviews the information submitted by the insurers to determine whether their proposed rates are justified. Rates must be justified both by the benefits that consumers receive for their premiums and by the insurance company's ability to pay expected medical claims costs based on premium revenue,' the agency noted. The agency indicated that the rate-review process requires insurers to provide coverage of pre-existing conditions and no-cost preventive care. The Commerce Department also verifies that insurers' networks of covered health care providers are adequate. Rate proposals represent average increases in prices. Prices for plans can vary depending on the consumer's age, tobacco use, family size and geographic location. They can also vary depending on the plan a consumer chooses and the renewal date of that plan. Recently, states have reported rate proposals for the 2023 plan year. New York regulators indicated average proposed rate increases of 18.7%. Washington state proposed increases are approximately 7%. [FN26] Health Insurance Transparency Rules Implemented The federal government recently implemented rules requiring certain health insurers to publicly disclose rates for in-network and out-of- network medical services. According to experts, early signs are indicating that insurers will comply with the Trump-era price transparency rule that was finalized two years ago. It went into effect in January 2022. However, CMS delayed enforcement of part of the rule last summer. THOMSON REUTERS © 2023 Thomson Reuters. No claim to original U.S. Government Works. -20- The agency delayed implementation due to the 'considerable time and effort" required to make the machine-readable files available under the regulations. The regulations require most group health plans and issuers of group or individual health insurance to post cost files online and update them monthly. Fines for noncompliance can be up to $100 per day for each violation and each patient affected. Companies serving many beneficiaries could face large fines. Under the rule, certain health plans must disclose in-network provider rates for all medical services and items covered by the plans. The insurers must also disclose the amounts they allowed as well as billed charges for out-of-network providers. The 'Transparency in Coverage" regulation aims to increase competition in the health care market by making prices more transparent prior to the point of service. It was designed to work with another rule the applies to hospitals and price transparency. Hospitals and payer groups have both lobbied against the rules and challenged them legally. Many hospitals in the industry have failed to comply with the price transparency rule. According to an analysis earlier this year, only 14% of hospitals complied with the rule. The rule requires hospitals to post online consumer-friendly price lists for common services. Another study showed only a 6% compliance rate. CMS fined two Georgia hospitals $1.1 million for noncompliance with the rule in June. Experts are hopeful that insurers will comply with the new rule rather than following the lead of hospitals. Early signs are positive. The largest private payer in the country, UnitedHealthcare, indicated that it will fully comply with the price transparency rules. The company already has a Transparency in Coverage website. Another insurer, Centene, mostly includes government plans. It has published machine-readable files for group health plans and individual market issuers online. Anthem, now Elevance Health, has done the same. Aetna, owned by CVS Health, indicated that it would comply in July. Other major parts of the new rule will become effective in 2023 and 2024. Insurers will have to disclose personalized pricing information for covered services to their enrollees through an online tool. They will also have to send out a paper copy upon request. The rule has a transparency requirement for prices of covered prescription medicines, however, that portion of the rule has been delayed indefinitely until additional rules are put in place. IFN27] Michigan Governor Urges Health Insurers to Cover Reproductive Care Governor Gretchen Whitmer recently sent letters to all major health insurance companies in Michigan urging them to cover reproductive health care 'to the fullest extent possible under current coverage." 'Today, | sent letters to all of Michigan's major health insurance providers urging them to take every action possible to fully cover reproductive health care in their plans," said Governor Gretchen Whitmer. 'With the recent U.S. Supreme Court decision overturning Roe v Wade, Michigan women must know that they can access the care they need, regardless of their insurance provider. | urge every major health insurance provider in Michigan to take action now to ensure Michigan women have coverage for reproductive health care to the fullest extent possible. This means offering in-person and telehealth care, lowering cost-sharing requirements, covering travel expenses for out-of-state care, and expanding contracts with providers who can offer safe, comprehensive reproductive care." Governor Whitmer filed a lawsuit earlier this year asking the Michigan Supreme Court to recognize a constitutional right to abortion under the Due Process Clause of the Michigan Constitution. The lawsuit also asked the court to halt enforcement of the 1931 Michigan abortion ban. After the Supreme Court of the United States ruled in the Dobbs decision, Governor Whitmer filed a motion asking the court to immediately consider her lawsuit and to clarify that access to abortion is legal and constitutionally protected in Michigan. The ban on abortion violates the due process clause in Michigan's constitution. The state constitution provides a right to privacy and bodily autonomy. According to Governor Whitmer, the state's near-total criminal ban of abortion 'also violates Michigan's Equal Protection Clause due to the way the ban denies women equal rights because the law was adopted to reinforce antiquated notions of the proper role for women in society." The current version of the Michigan law criminalizing abortion was enacted in 1931. It has no exceptions for rape or incest. The 1973 ruling in Roe v Wade rendered the Michigan law unconstitutional. A Michigan state judge granted a preliminary injunction on May 17, 2022, in a suit brought by Planned Parenthood against Michigan's unconstitutional 1931 law criminalizing abortion. [FN28] Study Shows Projected Effects Loss of Enhanced Subsidies Researchers from the Kaiser Family Foundation studied the potential effects of the loss of the enhanced health insurance subsidies. THOMSON REUTERS © 2023 Thomson Reuters. No claim to original U.S. Government Works. -24- Under the Affordable Care Act (ACA), Americans are eligible for subsidies to help cover the cost of health insurance premiums based on income level. The law caps the amount of a monthly premium for health insurance available through the individual market for income-eligible people and families based on income. The federal government provides tax subsidies to cover part or all of the cost of health insurance premiums based on a sliding scale. People with incomes just above the federal poverty level receive the most generous subsidies. People with incomes three to four times the poverty level pay more. The ACA included a subsidy cliff-those earning just over four times the federal poverty level were not eligible for any subsidies. Even a small amount over the cutoff led to a complete loss of federal tax subsidies for the cost of health insurance premiums. This phenomenon became known as the 'subsidy cliff." The American Rescue Plan Act (ARPA) temporarily expanded eligibility to subsidies, removing income caps for eligibility and limiting federal tax subsidies only by the cost of the plans relative to an individual or family's income. Higher income people were responsible for the cost of a silver plan up to 8.5% of their income. ARPA also increased the amount of federal subsidies available to people with lower incomes, again, temporarily. Congress is considering making these changes permanent. The cost would be approximately $22 billion per year. Without Congressional action, the ARPA enhanced subsidies will expire at the end of the year. The average cost of health insurance through a silver individual plan for a 40-year-old with income just over four times the poverty level (or $51,520 for an individual in 2022) would increase from 8.5% of income to 10% of income if Congress fails to extend the ARPA subsidies. The typical 40-year-old would face an increase from $365 per month to an unsubsidized $438 per month. The increase is about 20%. These numbers do not account for any price increases from the 2022 to 2023 plan year. Premium costs vary by state, so a person living in a high-premium state like West Virginia or Wyoming would have to pay an average of 18% of income for a silver plan without the enhanced subsidies. People living in states with lower premiums like Colorado, Maryland, Michigan, Minnesota, New Hampshire and Rhode Island already pay less than 8.5% of their income for a silver plan, so the loss of the enhanced subsidies would not affect them. Older residents in states with high premiums could face increases from paying 8.5% of their income for a silver plan to paying over 40% of their income, as a 64-year-old in West Virgnia or Wyoming earning just over the subsidy cliff would have to pay. IFN29] CMS Proposes Actions to Increase Access to Care in Rural Areas The Centers for Medicare & Medicaid Services (CMS) announced proposals for advancing health equity and improving access to care in rural areas. The agency is establishing policies for Rural Emergency Hospitals (REH). It will provide for payment of certain behavioral health services through communications technology. Also, along with President Biden's Executive Order on Promoting Competition in the American Economy, the calendar year (CY) 2023 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System proposed rule includes proposed enhanced payments under the OPPS and the Inpatient Prospective Payment System (IPPS) for the additional costs of purchasing domestically made NIOSH-approved surgical N95 respirators. 'CMS is taking action to ensure that people with Medicare in rural and underserved areas have improved access to high quality health care and to prepare for the next pandemic," said CMS Administrator Chiquita Brooks-LaSure. 'The proposals in this rule, if finalized, will expand access to care options in rural communities and permanently allow behavioral health services to be provided to people in their homes. We are also proposing to adjust payments to account for the cost of domestically made surgical N95 respirators to ensure that hospitals and their health care workers are ready for the next pandemic." 'Improving transparency of our health care system can help support people with Medicare get the high-quality, whole-person care they need," said Dr. Meena Seshamani, Deputy Administrator and Director for CMS' Center for Medicare. 'With this proposed rule, we are taking important steps forward to ensure that CMS is doing our part to make sure we have a competitive American health care system that works for all people with Medicare." The agency made proposals including establishing payment policies for rural emergency hospitals to improve access to care in rural communities. Proposals will establish payment rates for services provided at REHs. They will also create provider enrollment procedures for REHs. The Consolidated Appropriations Act of 2021 created this new provider designation. According to CMS, 'To advance health equity and improve access to care in rural areas, CMS is broadly proposing to consider all covered outpatient department services as REH services. CMS is proposing a higher payment rate for furnished REH services; REHs will receive the standard OPPS payment rate plus 5% for each REH service provided. In order to not limit the types of services that THOMSON REUTERS © 2023 Thomson Reuters. No claim to original U.S. Government Works. -29- REHs can provide, CMS is also proposing that REHs may provide certain outpatient services beyond those paid under the OPPS, and they would be paid the applicable fee schedule without the additional 5% payment." Under the statute, REHs would receive a monthly facility payment starting in CY 2023. This amount would increase annually based on the hospital market basket percentage beginning in CY 2024. CMS predicts that these payments will improve access to emergency services, observation care, and additional outpatient services in rural communities where hospitals are at risk of closing. The proposal also includes changes to OPPS payment for remote behavioral health services. CMS made emergency rulemaking changes in response to the COVID-19 public health emergency (PHE) to implement flexibilities to support providers and patient care in the face of the spreading pandemic. At the expiration of the PHE, many of the flexibilities will automatically expire. One flexibility that will end allows clinical staff of hospital outpatient departments to provide services remotely to patients in their homes for behavioral health. A proposed rule would allow payment to continue for these remote behavioral health services. This change would increase access to outpatient behavioral health services in rural areas and other underserved communities. [FN30] Inflation, Utilization Drives Increases in Health Insurance Costs Researchers recently released the results of a study showing that health insurance costs will increase in the coming year due to inflation, the COVID-19 pandemic, and nationwide policy changes. Researchers looked at the rate filings health insurers submitted to state regulators, which show predictions of the cost of health care in the coming year. According to researchers, 'These filings can provide insight into what factors insurers expect will drive health costs for the coming year." They reviewed rate filings from health insurers participating in the Affordable Care Act (ACA) Marketplaces to determine what insurers say are the reasons for increases in premium costs in the coming year. While a smaller number of Americans are enrolled in these plans than people who receive health insurance coverage through their employers, the filings are more detailed and are publicly available for analysis. Researchers looked at data from 72 insurers across 13 states and the District of Columbia, including Georgia, Indiana, lowa, Kentucky, Maryland, Michigan, Minnesota, New York, Oregon, Rhode Island, Texas, Vermont, and Washington. The rate filings were preliminary and are subject to change throughout the review process in each state. Rates are not expected to become final until the end of summer. The factors that researchers looked to as potentially increasing costs of health care coverage in 2023 were 'health cost trend (which includes health sector inflation and changes in utilization), the COVID-19 pandemic, and changes in federal policies (including the possible expiration of the American Rescue Plan Act subsidies, the implementation of the No Surprises Act, and the administrative fix to the Family Glitch)." Researchers found that insurers in the market proposed to increase premiums by larger percentages than in prior years. The median proposed premium increase was 10% across 72 insurers. They found cost trend to be the main factor in premium increases. This factor reflects the increase in prices paid to health care providers and pharmaceutical companies. It also reflects an increase in utilization of health care services that was temporarily decreased due to the COVID-19 pandemic. The main premium drivers of prices and utilization were found throughout the United States health care system. While the median proposed premium increase is approximately 10%, most insurers requested between 5% and 14% price increases for 2023 premiums. Fewer insurers are requesting to lower rates than in prior years. Only 4 out of 72 insurers filed with requested rate decreases. Researchers noted, 'In these filings, insurers describe factors they expect will have either an upward or downward impact on their costs for the coming year. Across all 72 filings, we systematically tracked key words relating to medical trend, the COVID-19 pandemic, and certain policy changes (the expiration of American Rescue Plan Act subsidies, the implementation of the No Surprises Act, and the Family Glitch administrative fix). We also searched for other key words relating to current issues like telemedicine and mental health, but we found most insurers did not reference these subjects in their filings. Insurers do not always publicly quantify all factors driving their premiums." Insurers calculate their projected health cost trend every year. This number is the sum of increasing payments to hospitals, doctors, and pharmaceutical companies, representing inflation, and expectations for utilization of health care services. Utilization includes the number of visits, stays, or prescriptions. Researchers called health cost trend a key driver of premium growth for the next year. Projections of health cost trend from insurers ranged from 4-8%. THOMSON REUTERS © 2023 Thomson Reuters. No claim to original U.S. Government Works. -23- According to the researchers, 'Although insurers are primarily interested in price growth in the health sector, given the unusually high pace of inflation in the rest of the economy, there is potential for general economic inflation to flow through to the health sector." They noted that 'Capital District Physicians Health Plan in New York warned of an imminent market correction, saying: "CPI for All goods and Services as of March 2022 was 8.5%, up 7% from pre-pandemic levels. Medical Care Services CPI in March 2020 (pre- pandemic) was 5.5% and as of March 2022 is 2.9%. This data suggests a correction is imminent as labor and supply cost increases directly impact hospitals and physician offices." Throughout the COVID-19 pandemic, most insurers expected the pandemic to have a neutral or slight negative or positive impact on costs. While hospitalization and vaccine administration increase costs, suppressed utilization was a downward effect on overall health care costs. [FNS1] Inflation Reduction Act Becomes Law, Extends Enhanced Subsidies President Biden signed the Inflation Reduction Act into law, which included a provision to extend the enhanced subsidies available to eligible consumers purchasing health insurance plans through the ACA marketplace. The temporary enhanced subsidies were created by the American Rescue Plan, the law aimed at addressing the COVID-19 pandemic that President Biden signed into law last year. The law increased the size of subsidies for people with lower incomes, reducing the amount they owed for monthly premiums for individual health insurance plans purchased through the ACA marketplace. The law also made people eligible for subsidies regardless of income, depending on the cost of coverage. The law limited the premium amount any consumer eligible for a plan through the ACA marketplace owed to 8.5% of income. The amount that consumers save as a result of the extension of the enhanced subsidy will vary. Prior to the ARP, consumers purchasing health insurance through the ACA marketplace were eligible for a federal subsidy only if they earned less than 400% of the federal poverty level. In 2022, 400% of the federal poverty level for an individual was $54,360. Anyone earning above that amount faced a subsidy cliff where they did not qualify for any federal healthcare subsidy, regardless of the cost of a benchmark plan for their age group in their geographic location. The cost of health insurance plans varies widely state by state, so people earning above the subsidy cliff could have faced significant increases in the cost of health insurance without the extension of the enhanced subsidies. U.S. Department of Health and Human Services (HHS) Secretary Xavier Becerra and Centers for Medicare & Medicaid Services (CMS) Administrator Chiquita Brooks-LaSure issued the following statements after President Biden signed the Inflation Reduction Act into law: Secretary Xavier Becerra: 'Since day one, the Biden-Harris Administration has made clear that making health care more accessible and affordable is a top priority. Under this Administration, more Americans than ever before have health insurance through Affordable Care Act coverage. 'Now, President Biden has signed into law one of the most consequential pieces of legislation in our lifetimes that will lower health care costs for millions of Americans. With the Inflation Reduction Act as law of the land, we will reduce drug costs for the more than 63 million people across the country with Medicare, and 13 million people covered under the Affordable Care Act will save $800 per year on their health insurance. 'At HHS, we are prepared to implement the Medicare drug negotiation and Part D redesign provisions of the Inflation Reduction Act. We are working closely with Congress to make sure that the task before us will be done to the highest standard, with all the necessary resources and expertise in place. '| thank everyone who has been in the fight advocating for these health care provisions for decades. Today, a new chapter of our work begins, and we stand ready to continue making high-quality, affordable health care within reach for everyone." CMS Administrator Chiquita Brooks-LaSure: 'The historic Inflation Reduction Act builds on the Biden-Harris Administration's efforts to meaningfully lower health care costs for people across the country. Millions of people with Medicare coverage will benefit from lower drug prices, a $35 monthly co-pay cap for insulin, a limit on out-of-pocket expenses in Medicare Part D, and reduced costs under Medicare's new ability to negotiate drug prices in the years ahead. In addition, the enhanced tax credits for the Affordable Care Act Marketplaces will continue for three years to help people afford their premiums and connect to coverage during the upcoming 10th Open Enrollment Period. CMS will be working with people covered by our programs, health industry stakeholders, states, and more as we work to make the law a reality for people across the country." [FNS2] New York Insurance Premiums to Increase The New York State Department of Financial Services (DFS) announced that it had approved premium rate increases for 2023. Superintendent of Financial Services Adrienne A. Harris emphasized that the rate increases were not as high as insurers had requested. The department denied the insurers request to increases rates by nearly $800 million over the approved rate increases. DFS reduced the requested rate increases by 48 percent in the individual market. The agency reduced insurers' requested rate increases by 52 percent. THOMSON REUTERS © 2023 Thomson Reuters. No claim to original U.S. Government Works. -24- The agency noted that 1.1 million New York residents are enrolled in individual and small group plans through the ACA marketplace. 'Rising medical costs and inflation continue to put upward pressure on premiums," said Superintendent Harris. 'With our rate actions announced today, we continue to prioritize the financial wellbeing of consumers while ensuring that New Yorkers have access to a robust, stable health insurance market." The agency pointed to the rising cost of medical care, including in-patient hospital stays and drug costs, as the main driver of insurance premium rate increases. Also, medical claims have increased as New Yorkers catch up on medical appointments and services postponed due to the pandemic. DFS indicated that it considered the continued uncertainty of the pandemic's effect on consumer's health care costs and the economy. It decided to limit insurers' profit provisions to a historically low 0.5%. In the individual market, insurers requested an average rate increase of 18.7 percent. DFS cut the requested rate increase by 48 percent to 9.7 percent for 2023. The agency estimated consumer savings at $167.1 million. The approved rates are subject to federal tax subsidies for eligible consumers, which will decrease monthly payments for some New York residents. In 2020, over 60% of New York residents who purchased health insurance plans through New York State of Health were eligible for federal premium tax credits to lower their monthly costs for coverage. An estimated 262,000 New York residents are currently enrolled in individual health insurance plans. The rate increases do not affect the Essential Plan. As of June 1, 2021, this plan was free for low-income New York residents. Over 1,000,000 people are currently enrolled. The small group plan in New York covers employers with up to 100 employees. Approximately 850,000 New York residents are enrolled in small group plans. Insurers requested average rate increases of 16.5% for small group plans. The agency reduced this request by 52% to 7.9% for 2023 plans. The requested increase for small group plans would have cost small businesses an additional $632.4 million. Some small businesses in New York will also be eligible for tax credits that could lower the cost of premiums. These credits include the Small Business Health Care Tax Credit. N34! Consumers to Receive Health Insurance Rebates The Kaiser Family Foundation estimated that 8.2 million health insurance consumers will receive approximately $1 billion in rebates by September 30th from various health insurers. The refunds will be an average of $141 per consumer for plans sold through the ACA marketplace. Plans available through a small employer will result in an average of a $155 rebate. People purchasing health insurance through large group plans can expect an average $78 rebate. People working for companies that self-insure will not receive a rebate. The total amount of the rebates will vary depending on the insurer and geographic location. In 2021 total rebates from health insurers were approximately $2 billion. In 2020 rebates were a record $2.5 billion. 'In the last couple of years we've seen some really large rebates - twice the size of this year's amount," said Cynthia Cox, a vice president at the foundation and director of its Affordable Care Act program. 'But I'd say $1 billion is still significant." Federal regulations require insurers to follow a medical loss ratio. They must spend at least 80% of premiums on health care costs and other expenses for patient health. Large group plans are required to follow an 85/15 ratio. If insurers fail to reach the medical loss ratio consumers receive a rebate for the difference. The ratio varies each year based on a rolling three-year average. The rebates for 2022 are based on financial data from 2019, 2020 and 2021, IN341 New Rule Clarifies Immigration Policy and Use of Healthcare Programs The U.S. Department of Homeland Security (DHS) issued a final rule that will help ensure that noncitizens can access health-related benefits and other supplemental government services without negative immigration consequences. The rule indicates how DHS will interpret the 'public charge" ground of inadmissibility. It codifies the 'totality of the circumstances" approach that is authorized under statute and that the agency has traditionally used. The rule indicates that individual factors, including disability or use of benefits alone, will not lead to a public charge determination. The final rule is relevant for noncitizens seeking admission to the United States or seeking lawful permanent residence. While determining if a person will become a public charge, or 'likely to become primarily dependent on the government for subsistence," the agency will not penalize individuals for accessing health-related benefits and other supplemental government services. Most Medicaid benefits, excepting long-term institutionalization, as well as benefits under the Children's Health Insurance Program (CHIP) are included. THOMSON REUTERS © 2023 Thomson Reuters. No claim to original U.S. Government Works. -25- DHS will also not consider the following government benefits: non-cash benefits provided by other government agencies including food and nutrition assistance such as the Supplemental Nutrition Assistance Program (SNAP); disaster assistance received under the Stafford Act; pandemic assistance; benefits received via a tax credit or deduction; and government pensions or other earned benefits. Receipt of cash-based benefits, such as Supplemental Security Income (SSI), Temporary Assistance for Needy Families (TANF), and other similar programs, will not automatically exclude an individual from admission or green card eligibility, and will instead be considered in a 'totality of the circumstances" analysis. The issue for HHS Secretary Xavier Becerra is in the overall interest of the nation for the good of public health. 'People who qualify for Medicaid, CHIP, and other health programs should receive the care they need without fear of jeopardizing their immigration status," said HHS Secretary Xavier Becerra. 'As we have experienced with COVID, it's in the interest of all Americans when we utilize the health care and other services at our disposal to improve public health for everyone." CMS Administrator Chiquitia Brooks-LaSure saw the rule as upholding the right to healthcare. 'This final rule reinforces a core principle of the Biden-Harris Administration: that healthcare is a right, not a privilege, and no one should be deterred from accessing the care they need out of fear," said CMS Administrator Chiquita Brooks-LaSure. 'Today's final rule is an important step toward achieving this goal for many Medicaid and CHIP enrollees and their families, and CMS will continue to do everything in our authority to make sure people have access to programs that keep them safe and healthy." Civil Rights Acting Director Melanie Fontes Ranier emphasized that federal law protects people applying for health benefits and government services. 'Federal civil rights laws require that all people be afforded fair and just decisions when applying for health benefits and other supplemental government services, free of bias, stigma, and discrimination," said Office for Civil Rights Acting Director Melanie Fontes Rainer. 'Today's rule sets up safeguards to help ensure that people with disabilities and older adults who are not U.S. citizens can access health care without fear. OCR will continue our robust enforcement of civil rights laws to ensure the rights of historically marginalized groups are upheld and defended." Alison Barkoff indicated that the rule will help people with disabilities and older people access healthcare without fear. 'People with disabilities and older adults who are not U.S. citizens no longer have to fear that using services that can help them maintain their health, live independently and contribute to their communities will cost them legal residency in our country," said Alison Barkoff, Acting Administrator of the Administration for Community Living. 'The rule explicitly rejects stereotypes that people with disabilities are more likely to become a public charge and is in keeping with the civil rights protections that are the bedrock of American values." The Biden-Harris Administration took action in 2021 leading up to this final rule. The action was in response to the previous administration's 2019 public charge rule which discouraged immigrants from seeking healthcare benefits for which they and their children were eligible because of fearing immigration consequences. According to HHS, 'This chilling effect extended even to those categories of noncitizens who, by law, are exempt from the public charge ground of inadmissibility, including refugees, asylees, noncitizens applying for or re-registering for temporary protected status (TPS), special immigrant juveniles, T (trafficking victims) and U (crime victims) nonimmigrants, and self-petitioners under the Violence Against Women Act (VAWA)." The final rule is an effort to reverse the harmful effects and to make those programs accessible to people in need. [FN35] Texas has Highest Rate of Uninsured Residents The census showed that Texas has the highest rate of residents lacking health insurance coverage. Healthcare advocates indicated that the need is significant for the state to expand access to Medicaid. According to the U.S. Census Bureau, 18% of Texas residents lacked health insurance last year. Texas has had the highest rate of uninsured residents of all states for years. Anne Dunkelberg, a policy analyst with the nonprofit Every Texan, noted that the state also has the highest rate of uninsured children at almost twice the national average. 'Texas has a hugely problematic uninsured rate,' she said. 'We ... have the worst uninsured rate for kids in the county, which is huge. The uninsured rate average for all 50 states is 5.4%, and here in Texas our uninsured rate for kids was 12%." According to Dunkelberg, the rate of Texas residents without health insurance coverage has remained about the same since the last time the Census Bureau released data in 2019. She credited federal protections that prevented clients from being removed from the Children's Health Insurance Program and Medicare with preventing an increase in the percentage of Texas residents without coverage. Brian Sasser, chief communications officer with the Episcopal Health Foundation, indicated concern over the expiration of those protections potentially leading to a higher rate of uninsured people living in Texas in 2023. THOMSON REUTERS © 2023 Thomson Reuters. No claim to original U.S. Government Works. -26- 'The bottom line is that these advantages have helped,' he said. 'They've made a dent in the uninsured rate in Texas, but we're still by far the worst. It's really not that close.' The new census numbers revealed that Oklahoma was second to last with a population that is 13% uninsured. Texas is last in both the insured rate of children and adults with an overall uninsurance rate of 18%. The data showed that almost 1 in 4 working Texans did not have health insurance coverage last year. Sasser pointed to the cost of plans available under the Affordable Care Act, asserting that uninsured working adults might not make enough money to cover premiums. They also do not qualify for coverage under the Children's Health Insurance Program or Medicare. Sasser is in favor of expanding access to Medicaid to reach the currently uninsured people of Texas. A recent study showed that expanding Medicaid eligibility in Texas could bring $5.4 billion in federal funding to help cover the cost of expansion. Republican legislators in the state have blocked expansion of the program, asserting that it's mismanaged and that the state could provide an alternative program. Bills that would expand Medicaid were not even brought to a hearing in the Texas House and Senate committees last year. '| think the argument has been made over and over again. It seems like the hang up [has] nothing to do with all the facts of the case,' Sasser said. 'The frustration is that there's a tool out there to help fix this issue, but it's not being used.' According to Sasser, a recent poll showed that almost 70% of Texas residents are in favor of expanding Medicaid. Dunkelberg pointed to the fact that many of the working Texas residents without health insurance coverage are people of color. 'The fact that, of the uninsured and working poor in Texas, 75% of them are Texans of color suggests to us that we need to be paying more attention to making public policy choices,' she indicated. [FN36] Mobile Healthcare Legislation Passes House and Senate Legislation that would allow community health centers to use federal funding to create new mobile health care delivery sites has passed the United States House and Senate. It will now go to President Biden to be signed into law. U.S. Senators Jacky Rosen (D-NV) and Susan Collins (R-ME), and Representatives Susie Lee (D-NV) and Richard Hudson (R- NC) drafted the legislation, the bipartisan, bicameral Maximizing Outcomes through Better Investments in Lifesaving Equipment for (MOBILE) Health Care Act. The legislators created the bill particularly to meet the needs of people living in rural areas and other populations struggling to access medical care. 'Too many of Nevada's rural and underserved communities lack permanent health centers and reliable health care, which make mobile health centers indispensable in reaching them," said Senator Rosen. 'We have to make health care more accessible, which is why I'm thrilled that my bipartisan bill to provide greater resources to expand mobile health clinics is on its way to the President's desk to become law." Rural areas depend on community health centers to provide health care to geographically isolated residents. Mobile units will help people living in rural areas access care. 'Community health centers in Maine and across the country play an indispensable role in ensuring that rural and underserved communities receive affordable and quality health care," said Senator Collins. 'The MOBILE Health Care Act would help community health centers further expand their reach to the most rural parts of our state by giving them greater flexibility and allowing them to bring clinics even closer to the patients they serve." Legislators were motivated by the need to expand access to care to more of their constituents, with the ultimate goal of access for residents of all states in all areas. 'The pandemic laid bare longstanding inequities in our health care system, and I'm fighting to make health care more accessible to Nevadans, no matter where they live," said Rep. Susie Lee. 'Federally-Qualified Health Centers provide essential care for thousands of Nevada families who need it. With the passage of this bill, we're one step closer to ensuring that every Nevadan has access to the care they deserve. I'm so proud that the House and Senate voted to pass this important legislation, and | look forward to President Biden signing this bill into law." 'The MOBILE Health Care Act is critical to improve health care quality and access across our country, especially in rural and underserved areas," said Rep. Richard Hudson. 'I have heard directly from community health centers in North Carolina and across the country about the positive impact this bill and the flexibilities it provides would have on communities and patients, and | look forward to getting it across the finish line." 'On behalf of Community Health Centers and the 30 million patients they serve, | want to thank Senator Jacky Rosen and Senator Susan Collins for pushing this important bill to extend access to high-quality primary care to rural communities through an expansion of mobile clinics," said Rachel Gonzales-Hanson, Interim President and CEO of the National Association of Community Health Centers (NACHC). 'Nearly half of health centers are located in rural and frontier communities, but we know there is still unmet need. Additional mobile health clinics have the potential to leverage the reach of health centers and fully serve hard-to-reach across the country patients." THOMSON REUTERS © 2023 Thomson Reuters. No claim to original U.S. Government Works. -27- Health care providers supported the passage of the legislation. 'The Nevada Primary Care Association is comprised of the state's Community Health Centers which provide integrated primary care, behavioral health and dental care to more than 111,000 Nevadans annually," said Nancy Bowen, CEO, Nevada Primary Care Association. 'We are profoundly grateful to Congresswoman Susie Lee and Senator Rosen for passing the MOBILE Health Care Act to make it easier for our health centers to finance mobile health units. These mobile units may offer primary or dental care or provide specialty services such as mammography to sparsely populated rural areas or to underserved populations in our urban centers. This can include visiting homeless resource centers or senior housing where residents have limited ability to travel for care. Some of Nevada's rural areas cannot support permanent medical facilities, making this bill revolutionary for the health centers seeking to provide these communities with health care.* FN371 Medicaid Expansion Lowered Uninsured Rate in Nebraska New data shows that the number of uninsured people in Nebraska has declined significantly in the two years since the state expanded access to Medicaid coverage. Additionally, data shows that hospitals are less financially stressed and fewer people in the state are filing for bankruptcy. Senator Adam Morfeld of Lincoln pointed to the results as the argument that advocates made for expansion for six years prior to legislative approval and during the successful campaign to pass an expansion initiative for Medicaid through voters. 'The data only affirms what we promised Nebraskans: that our family members, neighbors and friends would be more healthy, financially secure and lead longer and happier lives," he said. 'This also reduces the burdens on rural hospitals that often struggle to stay open and increases access and reduces health care costs for all Nebraskans." Morfeld was a leader in putting the Medicaid expansion measure on the general election ballot in 2018. Prior to the ballot initiative, two governors, Dave Heineman and Pete Ricketts, and multiple state lawmakers decided against the expansion of Medicaid to more low- income Nebraska residents. The Ricketts administration did not implement the program to expand eligibility for Medicaid in Nebraska for nearly two years after the ballot measure passed, which was the longest that any state delayed in carrying out expansion from a ballot measure. While coverage began October 1, 2020, enrollees did not gain full Medicaid benefits for another year after implementation. After Medicaid expansion in Nebraska: -The number of Nebraskans without health insurance has dropped 14.5%. -Nebraska hospitals saw a $20 million reduction in the amount of charity or unpaid care they had to write off. -Bankruptcy filings in the state fell by 23.5%. According to Sarah Maresh, health care access program director for Nebraska Appleseed, a strong advocate for the expansion campaign, the changes are similar to changes in other states after Medicaid expansion. The Affordable Care Act allowed states to expand eligibility for Medicaid. Thirty-eight states and the District of Columbia have agreed to the expansion through legislative action or ballot initiative. 'We're just really excited to see this come to fruition," said Maresh. 'The health of our state depends on the health of individuals." The governor was asked if Nebraska was better off after Medicaid expansion. He declined to answer but his staff released a statement: 'Gov. Ricketts' team at the Nebraska Department of Health and Human Services has worked hard to effectively roll out Medicaid expansion to Nebraska, per the will of the people." Expansion of Medicaid in Nebraska was stalled due to contentious and partisan positions and arguments closely related to stances over the Affordable Care Act, which President Barack Obama signed into law in 2010. The Affordable Care Act aimed to reduce the number of uninsured people in the United States, especially those who could not access health insurance through their employers and who did not make enough to afford to purchase it through the open market. The ACA provided subsidies to help with the cost of premiums for some people purchasing individual plans through the state and federal health insurance exchanges/marketplaces. However, the law provided that people earning below the federal poverty line could become eligible for coverage under Medicaid, a joint state-federal health care program for people with low incomes. The U.S. Supreme Court ruled that Medicaid expansion was not mandatory for states. People living in states that did not agree to the expansion could not access the coverage. That ruling led to years of struggle in states like Nebraska and many other Republican-led states that did not agree to the expansion. Under the Nebraska voter initiative, the state has finally expanded Medicaid eligibility to single adults and couples without minor children. Prior to expansion, adults without children could not qualify for Medicaid coverage regardless of their income level. The expansion also widened eligibility for parents and disabled people with incomes higher than prior eligibility cutoffs. THOMSON REUTERS © 2023 Thomson Reuters. No claim to original U.S. Government Works. -28- In Nebraska, the percentage of residents without health insurance coverage decreased from 8.3% in 2019 prior to expansion, to 7.1% in 2021, [N38 Underinsured People Remain Even as Uninsured Rate has Decreased The rate of Americans without health insurance coverage has decreased to historic lows but many people remain uninsured or underinsured. The increase in the number of people with health insurance coverage is due to the federal policy changes aimed at increasing coverage during the COVID-19 public health emergency, results from a recent survey showed. At the same time, many people have inadequate health insurance coverage. Many people are expected to lose coverage completely with the expiration of pandemic measures when the public health emergency ends. According to the survey, 43% of adults had inadequate health insurance coverage in 2022. Nine percent of respondents had no health insurance, 11% had a coverage gap, and 23% had coverage that did not provide affordable care. Of people who reported having no health insurance coverage, 79% of them reported having no coverage for a year or longer. People without health insurance coverage for a year or more were often poor, young, and Latinx/Hispanic. They also often were in fair or poor health or had a chronic health problem. They were also more likely to live in the southern United States. Of people who had health insurance coverage through their employers, 29% were underinsured. This number grew to 44% for people who purchased their own health insurance coverage through the individual marketplace. The cost of care, even for people with health insurance coverage, affect patient care. Forty-six percent of survey respondents reported that they had skipped needed health care or delayed it due to cost. Forty-two percent of respondents said they had problems paying medical bills or had medical debt. Nearly half of respondents, 49%, indicated that they would be unable to cover the cost of a $1,000 medical bill within 30 days. These respondents included low-income people (68%), Black adults (69%), and Latinx/Hispanic adults (63%). Patients reported the following cost-saving measures: not going to the doctor when sick, skipping a recommended follow-up visit or test, not seeing a specialist when recommended, or not filling a prescription. Voters considered healthcare a top priority, including 68% of Democrats, 55% of independents, and 46% of Republicans. Researchers surveyed 6,301 people ages 19 to 64. [FNS8] Survey Reveals Coverage Concerns The recent survey from the Commonwealth Fund showed that the number of people with health insurance in the United States has increased to a historic high during the COVID-19 pandemic, but that many people still had inadequate coverage. While more people have health insurance coverage, many of those plans only offer limited financial protection. People who need medical care or prescriptions have to pay sometimes high out-of-pocket costs. The Commonwealth Fund is a private research foundation that promotes high quality, equitable health care. Researchers released the results of the survey as other health insurance data also came to light, some of it through the U.S. Census Bureau from the annual American Community Survey. This data showed that federal laws passed in response to the pandemic have led to gains in health insurance coverage for more people in the United States. Almost 299 million Americans were insured in 2021, which was a historically high number. The number of people without health insurance in 2021, just over 28 million, decreased by 1.4 million people since 2019. Federal pandemic protections prevented states from disenrolling people from Medicaid. Federal law also increased subsidies to lower the cost of premiums for individual health plans purchased through the Affordable Care Act marketplace. The increase in health insurance coverage hasn't created financial protection for some people from high medical costs. Some of those people have avoided necessary medical care or medications due to cost. The Affordable Care Act requires health insurance plans to cover certain benefits. However, insured beneficiaries are still responsible for copays and deductibles for most medical care and medications. 'The big "but' is that while it's great that more people have insurance coverage, it's also half the battle," said Gideon Lukens, director of research and data analysis for health policy at the left-leaning research institute, the Center on Budget and Policy Priorities. "You still have to make sure people with coverage have access and don't have to sacrifice their financial security to get it." According to Sara Collins, a Commonwealth senior scholar and vice president who co-authored an analysis of the research, the result is a lack of access to needed medical care for underinsured people. THOMSON REUTERS © 2023 Thomson Reuters. No claim to original U.S. Government Works. -29- 'If you're delaying medical visits or not getting prescriptions filled because of costs, that means your overall health is not as good as it might have been," she said. 'That is an impact not only on individual lives but the productivity of employers and the overall well-being of the economy. And on the financial side, it is having a massive impact on people in terms of medical debt." Researchers considered the following factors when characterizing someone as underinsured: -Excluding health insurance premiums, an individual during the previous 12 months faced out-of-pocket health expenses amounting to at least 10% of the household's income. -Out-of-pocket costs apart from premiums over the previous year were at least 5% of a household's income for an individual whose income was under 200% of the federal poverty line (in 2022, that is $27,180 for an individual or $55,500 for a family of four). -The health plan's deductible requirement constituted 5% or more of the household income. According to researchers, over 4 in 10 people who purchased individual health insurance plans during 2022 were underinsured, including people who purchased those plans through the Affordable Care Act marketplaces. Almost 30% of people who received employer-sponsored health insurance coverage were also underinsured. U.S. Census Bureau data showed that over 164 million people received health insurance through their employers in 2021. Sixty-one percent of people who were underinsured and 71% of people who were uninsured for part of the year failed to obtain necessary medical care due to cost. Less than one third of people who had adequate health insurance coverage for the entire year failed to obtain necessary medical care. A significant number of people with chronic health conditions declined to fill prescriptions due to cost. At least 25% of people with diabetes, lung diseases such as emphysema and those who had heart failure or a heart attack did not fill prescriptions due to cost in the previous year. Many underinsured people faced issues related to medical debt, such as making sacrifices to pay out-of-pocket medical costs. They also had negative consequences to credit ratings, had to resort to savings, and were unable to pay for necessities including food, heat, mortgage payments, or rent. According to Collins, one of the best ways to improve access to adequate health insurance coverage is Medicaid expansion in the 12 states that have refused to increase eligibility for the program that covers low-income people. Most of those 12 states are in the southern United States. Under the Affordable Care Act, all adults with incomes up to 138% of the federal poverty level qualify for Medicaid, but only if their state of residence has agreed to expand the program. Expansion in those 12 states would bring adequate health insurance coverage to 3.7 million people. [FN40] Rule Assists Seniors Transitioning from Medicaid to Medicare The Biden Administration recently announced a final rule to create a new Medicare special enrollment period for seniors currently enrolled in Medicaid. The new rule will also waive any late-enrollment fees for failing to enroll in Medicare due to the COVID-19 Public Health Emergency. According to Senator Maggie Hassan, 'Granite State seniors shouldn't have to worry about losing their health insurance once the COVID emergency declaration formally ends. I'm pleased to see the administration heed my call so that seniors can have a seamless transition to Medicare and not experience any gaps in their health care coverage." At the start of the COVID-19 public health emergency, Congress passes a law that expanded Medicaid coverage for more children, working adults, and older Americans to ensure they had access to health insurance coverage during the pandemic. At the end of the federal declaration of a public health emergency, now set for January 11, the expanded coverage will end. States will begin removing enrolled people from Medicaid coverage without eligibility renewals. Older Americans who qualify for Medicare but did not enroll yet because they were still receiving health insurance coverage through Medicaid will also be disenrolled. Several Senators called the Centers for Medicare and Medicaid Services (CMS) earlier in 2022 to advocate for a special enrollment period for Medicaid beneficiaries to enroll in Medicare coverage. Without the rule change, some people would face late enrollment fees. Those fees will now be waived beginning January 1, 2023. IFNA4] Final Rule to Improve Rural Healthcare Equity The U.S. Department of Health and Human Services (HHS), through its Centers for Medicare & Medicaid Services (CMS) announced improvements in access to healthcare including behavioral health services in rural communities. HHS indicated that the changes reflect the Biden-Harris Administration's commitments to advancing health equity and to improving the nation's behavioral health services. THOMSON REUTERS © 2023 Thomson Reuters. No claim to original U.S. Government Works. -30- CMS is releasing the calendar year (CY) 2023 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System final rule. There is also a comment period. The rule will allow Critical Access Hospitals (CAHs) and small rural hospitals to convert to a Rural Emergency Hospital (REH). The change might be an improvement in sustainability for rural hospitals facing closure. It also supports access to care in rural and underserved communities. REH is a new Medicare provider type. It includes outpatient services, emergency services, and observation care. Under the new rule, Medicare will pay hospital outpatient departments to provide remote behavioral health services to people in their own homes. The changes will improve access to healthcare in rural areas and help to improve health equity. 'The Biden-Harris Administration continues to take steps to ensure all Americans, regardless of where they live, have access to high- quality, affordable health care, and this is especially important in rural America, where many hospitals have closed over the past two decades," said HHS Secretary Xavier Becerra. 'By helping rural hospitals stay open, we are helping residents of rural areas get the care they need close to home. Having access to care nearby is not only more convenient, but also leads to better health outcomes - and boosts local economies." 'CMS is committed to expanding access to care in rural communities and ensuring people with Medicare get the high-quality care they need," said CMS Administrator Chiquita Brooks-LaSure. 'Through the establishment of Rural Emergency Hospitals, supporting Clinic visits at rural sole community hospitals and enabling people with Medicare to remotely access behavioral health services in their homes, today's actions promote patient safety, equity, and quality for these underserved communities. We received broad support for the role Rural Emergency Hospitals can play in advancing health equity and thank stakeholders for their thoughtful input during the public comment period." 'Establishing Rural Emergency Hospitals can help ensure continued access to critical medical facilities in rural communities," said Deputy Administrator and Director for the Center for Medicare, Dr. Meena Seshamani. 'These facilities are often backbones of communities, but maintaining these businesses and keeping doors open can be challenging. Under today's final rules regarding this new provider type, we hope to preserve and improve access to care in rural areas and take important steps toward advancing health equity nationwide." In addition, CMS is updating the CY 2023 OPPS payment rates and ASC payment rates by 3.8%. CMS is in the process of finalizing factors for REHs, including conditions of participation, payment rates, and Medicare enrollment requirements. Congress created the REH, a new type of Medicare provider, in the Consolidated Appropriations Act, 2021. The policies for REHs will begin January1, 2023. According to HHS, 'Rural hospitals are essential for providing health care in their communities, and the closure of these hospitals limits access to care in areas that are often already underserved. The availability of the REH designation will help support access to health care, particularly emergency services and outpatient services. The REH requirements in this final rule establish a full range of health and safety standards, requirements for services offered, staffing requirements, and physical environment and emergency preparedness standards. REHs will receive additional Medicare payments to help maintain access to a wide array of services in rural areas." The new policy created by CMS will improve access to behavioral health services in rural areas. Clinical staff of hospital outpatient departments will be able to provide behavioral health services remotely to patients in their homes. The policy first came into effect under emergency rulemaking in response to the COVID-19 public health emergency. CMS will now make the policy permanent, improving access to behavioral health services for rural and other underserved communities. This change is aimed at making healthcare more equitable, particularly for people living in rural areas. [FN42] Health Insurance Costs Show Slight Increases for Employers, Employees A recent survey by the Kaiser Family Foundation showed that the cost of employer-sponsored health insurance coverage remained similar to costs from last year. The average cost of annual family premiums for employer-sponsored health insurance was $22,463. Last year the average cost was $22,221, according to the 2022 benchmark KFF Employer Health Benefits Survey. Workers contributed an average of $6,106 toward the cost a family premium. Employees who had annual deductible for single plans paid an average of $1,763. Lat year, the average deductible was $1,669. A decade ago, average yearly deductibles were $1,097 for single employer-sponsored plans. 'Employers are already concerned about what they pay for health premiums, but this could be the calm before the storm, as recent inflation suggests that larger increases are imminent," KFF President and CEO Drew Altman indicated. 'Given the tight labor market and rising wages, it will be tough for employers to shift costs onto workers when costs spike." According to the survey, disparities in the burden of health care costs remain for workers at smaller and large employers. Employees of companies with less than 200 workers paid an average of $7,556 annually for family coverage. At larger firms they paid an average of $5,580. THOMSON REUTERS © 2023 Thomson Reuters. No claim to original U.S. Government Works. -31- Workers at smaller companies also paid a much larger average deductible, $2,543 vs. $1,493. Almost half of all workers at small firms face average deductibles of $2,000 or more. Only 25% of workers at larger firms face a deductible that expensive. The survey was the 24th annual survey of over 2,100 small and large employers. Nearly 159 million Americans access health insurance coverage through an employer. The modest increases in premium costs are expected to end in 2023 as inflation catches up with the cost of health insurance. Price increases in 2022 did not keep up with inflation (8%) or workers' wages (6.7%). Since 2012, average premiums for family coverage have increased 43% since 2012, outpacing inflation (25%) and wages (38%) over the same period. [FN43] © Copyright Thomson/West - NETSCAN's Health Policy Tracking Service [FN2] . Press release, "HHS to Make Coverage More Accessible and Affordable for Millions of Americans in 2023," CMS Newsroom, December 28, 2021, available at https:/Avww.cms.gov/newsroom/press-releases/hhs-make-coverage-more-accessible-and-affordable- millions-americans-2023. [FN3] . Appleby, Julie, "Here's what the new ban on surprise medical billing means for you," Shots Health News from NPR, December 30, 2021, available at https://www.npr.org/sections/health-shots/2021/10/14/1045828215/ban-on-surprise-medical-bills. [FN4] . Press release, "Ahead of January 15th Open Enrollment Deadline, New Numbers Show 14.2 Million Americans Have Quality, Affordable Coverage - Many With Even Lower Deductibles Under the American Rescue Plan," CMS Newsroom, January 13, 2022, available at https:/Avww.cms.gov/newsroom/press-releases/ahead-january-15th-open-enrollment-deadline-new-numbers-show-142- million-americans-have-quality. [FN5] . Press release, "NEW STATE-BY-STATE REPORT: In 37 States, Workers' Health Insurance Premiums and Deductibles Take Up 10 Percent or More of Median Income," The Commonwealth Fund, January 12, 2022, available at file:///C:/ Users/Owner/Downloads/News Release.pdf. [FN6] . Jones, Blake, "Statehouse roundup, 2.3.22: School employee health insurance boost heads to governor," /daho Capital Sun, February 3, 2022, available at https://idahocapitalsun.com/2022/02/03/statehouse-roundup-2-3-22-school-employee-health-insurance-boost- heads-to-governor/. [FN7] . Press release, "Statement by President Biden on 14.5 Million Americans Signing up for Health Insurance," The White House, January 27, 2022, available at https:/Avww.whitehouse.gov/briefing-room/statements-releases/2022/01 /27/statement-by-president-biden- on-14-5-million-americans-signing-up-for-health-insurance/. [FN8] . Vande Graaf, Matt, and Elizabeth Beverly, "Support health care for every child in Virginia," Virginia Mercury, February 3, 2022, available at https:/Awww.virginiamercury.com/2022/02/03/support-health-care-for-every-child-in-virginia/. [FN9] . Press release, "Governor Lamont Introduces Comprehensive Package of Legislative Proposals on Healthcare," February 10, 2022, available at https://portal.ct.gov/Office-of-the-Governor/News/Press-Releases/2022/02-2022/Governor-Lamont-Introduces- Comprehensive-Package-of-Legislative-Proposals-on-Healthcare. [FN10] . Press release, "Sens. Carper, Coons Urge Biden Administration to Limit Junk Health Plans That Undermine Standards of Affordable Care Act," insurancenews.net, February 16, 2022, available at https://insurancenewsnet.com/oarticle/sens-carper-coons-urge-biden- administration-to-limit-junk-health-plans-that-undermine-standards-of-affordable-care-act. THOMSON REUTERS © 2023 Thomson Reuters. No claim to original U.S. Government Works. -32- [FN11] . Press release, "New HHS Report Highlights 40 Percent Decline in Uninsured Rate Among Black Americans Since Implementation of the Affordable Care Act," HHS Newsroom, February 23, 2022, available at https:/Awww.hhs.gov/about/news/2022/02/23/new-hhs- report-highlights-40-percent-decline-in-uninsured-rate-among-black-americans-since-implementation-affordable-care-act.html. [FN12] . Ibarra, Ana B., "Millions of Californians at risk of losing health coverage when federal COVID programs end," Cal Matters, March 4, 2022, available at https://calmatters.org/health/2022/03/california-health-insurance-federal-programs-expire/. [FN13] . Press release, "On 12-Year Anniversary of the Affordable Care Act, New HHS Report Shows Ways the Biden-Harris Administration's American Rescue Plan Investments Are Lowering Health Care Costs and Expanding Coverage," CMS Newsroom, March 23, 2022, available at https:/Awww.cms.gov/newsroom/press-releases/12-year-anniversary-affordable-care-act-new-hhs-report-shows-ways- biden-harris-administrations. [FN14] . Alonso-Zaldivar, Ricardo, "End of COVID Could Bring Major Turbulence for U.S. Health Care," Manufacturing Business Technology, March 31, 2022, available at https:/Awww.mbtmag.com/business-intelligence/news/22 144535/end-of-covid-could-bring-major- turbulence-for-us-health-care. [FN15] . Rowland, Darrel, "Ohio House votes to end health insurance copay tactic that's 'ruining a lot of families'," The Columbus Dispatch, March 31, 2022, available at https://www.dispatch.com/story/news/2022/03/31/ohioans-would-get-protection-making-health-insurance- copays-accumulators-rare-chronic-disease/7209047001/. [FN 16] . Press release, "FACT SHEET: The Biden Administration Announces New Actions to Lessen the Burden of Medical Debt and Increase Consumer Protection," The White House Briefing Room, April 11, , available at https:/Avww.whitehouse.gov/briefing-room/statements- releases/2022/04/1 1/fact-sheet-the-biden-administration-announces-new-actions-to-lessen-the-burden-of-medical-debt-and-increase- consumer-protection/. [FN17] . Press release, "HHS Announces New Policy to Make Coverage More Accessible and Affordable for Millions of Americans in 2023," HHS Newsroom, April 28, 2022, available at https:/Avww.hhs.gov/about/news/2022/04/28/hhs-announces-new-policy-make-coverage- more-accessible-affordable-for-millions-americans-in-2023.html. [FN18] . "New report shows impact of rising health care costs on Oregon families," Tillamook Headlight Herald, April 25, 2022, available at https:/Avww.tillamookheadlightherald.com/news/new-report-shows-impact-of-rising-health-care-costs-on-oregon-families/ article_e057b44c-c4cd-1 1ec-8980-6b4cf37e6cdd.html. [FN19] . Press release, "New Reports Show Record 35 Million People Enrolled in Coverage Related to the Affordable Care Act, with Historic 21 Million People Enrolled in Medicaid Expansion Coverage," CMS.gov, April 29, 2022, available at https:/Avww.cms.gov/newsroom/press- releases/new-reports-show-record-35-million-people-enrolled-coverage-related-affordable-care-act-historic-21. [FN20] . "NEARLY 30 MILLION AMERICANS HAD NO HEALTH INSURANCE DURING THE FIRST YEAR OF THE PANDEMIC," Peter G. Peterson Foundation, May 2, 2022, available at https:/Awww.pgpf.org/blog/2022/05/nearly-30-million-americans-had-no-health- insurance-during-the-first-year-of-the-pandemic. [FN21] . Press release, "New Study: No Surprises Act Prevented Over Two Million Potential Surprise Bills for Insured Americans," AHIP, May 24, 2022, available at https:/Avww.ahip.org/news/press-releases/new-study-no-surprises-act-prevented-over-two-million-potential- surprise-bills-for-insured-americans. [FN22] THOMSON REUTERS © 2023 Thomson Reuters. No claim to original U.S. Government Works. -33- . Press release, "Washington state seeks federal approval to expand health insurance to previously uninsured," Washington Health Benefit Exchange, May 16, 2022, available at https:/Avww.wahbexchange.org/Washington-state-seeks-federal-approval-to-expand- health-insurance-to-previously-uninsured/. [FN23] . Cohn, Meredith, "COVID-19 likely to make health insurance more expensive for many in Maryland," The Baltimore Sun, May 25, 2022, available at https:/Awww.baltimoresun.com/health/bs-hs-health-exchange-rates-may-rise-20220525-clfbbf74gvanxhzvch4xk43hoq- story.html. [FN24] . Press release, "Friday Health Plans Raises $120 Million in New Funding to Support Enrollment Growth," Cision PR Newswire, May 25, 2022, available at https:/Avww.pmewswire.com/news-releases/friday-health-plans-raises-120-million-in-new-funding-to-support- enrollment-growth-301554554. html. [FN25] . "Fact Sheet: What happens to premiums if the extra help from the American Rescue Plan expires?," HHS.gov, June 22, 2022, available at https:/Awww.hhs.gov/about/news/2022/06/22/fact-sheet-what-happens-premiums-if-extra-help-american-rescue-plan- expires.html. [FN26] . Snowbeck, Chris, "Health insurers seek premium increases up to 6% in Minnesota's individual market [FN27] . The range of proposed changes is lower than what carriers sought last summer for 2022 coverage," Star Tribune, June 21, 2022, available at https://www.startribune.com/health-insurers-seek-premium-increases-up-to-6-in-minnesotas-individual- market/600183902/.F NA#27. Pifer, Rebecca, "CMS insurer price transparency rule has taken effect. Signs are good for compliance," HealthCare Dive, July 1, 2022, available at https:/Avww.healthcaredive.com/news/insurer-price-transparency-takes-effect- compliance/626449/. [FN28] . Press release, "Whitmer Calls on Michigan Insurers to Ensure Women Have Coverage for Reproductive Health Care," June 29, 2022, available at https:/Avww.michigan.gov/whitmer/news/press-releases/2022/06/29/whitmer-calls-on-michigan-insurers-to-ensure-women- have-coverage-for-reproductive-health-care#:?:text=S%# Today# | sent letters to,#S%o said Governor Gretchen Whitmer. [FN29] . Cox, Cynthia, "Falling off the Subsidy Cliff: How ACA Premiums Would Change for People Losing Rescue Plan Subsidies," KFF, June 30, 2022, available at https:/Avww.kff.org/policy-watch/falling-off-the-subsidy-cliff-how-aca-premiums-would-change-for-people-losing- rescue-plan-subsidies/. [FN30] . Press release, "CMS Proposes Rule to Advance Health Equity, Improve Access to Care, and Promote Competition and Transparency," CMS.gov, July 15, 2022, available at https:/Avww.cms.gov/newsroom/press-releases/cms-proposes-rule-advance- health-equity-improve-access-care-and-promote-competition-and-transparency. [FN31] . Ortaliza, Jared, et al., "An early look at what is driving health costs in 2023 ACA markets," Peterson-KFF Health Tracker System, July 18, 2022, available at https:/Awww.healthsystemtracker.org/brief/an-early-look-at-what-is-driving-health-costs-in-2023-aca-markets/ #Distribution of proposed 2023 rate changes among 72 reviewed ACA marketplace insurers. [FN32] . Press release, "Statements by HHS Secretary Xavier Becerra, CMS Administrator Chiquita Brooks-LaSure on President Biden Signing Inflation Reduction Act into Law," HHS.gov, August 16, 2022, available at https:/Avww.hhs.gov/about/news/2022/08/16/statements-hhs- secretary-xavier-becerra-cms-administrator-chiquita-brooks-lasure-on-president-biden-signing-inflation-reduction-act-into-law. html. [FN33] . Press release, "DFS ANNOUNCES 2023 HEALTH INSURANCE PREMIUM RATES, & #8239;SAVING NEW YORKERS $799.5 MILLION," New York State, August 17, 2022, available at https:/Awww.dfs.ny.gov/reports_and_publications/press_releases/ pr202208171. THOMSON REUTERS © 2023 Thomson Reuters. No claim to original U.S. Government Works. -34- [FN34] . O'Brien, Sarah, "PERSONAL FINANCES8.2 million people may soon get health insurance rebates up to an average $155 per person," CNBC, August 12, 2022, available at https:/Avww.cnbc.com/2022/08/12/8point2-million-people-may-soon-get-a-rebate-from-their- health-insurer.html. [FN35] . Press release, "New Rule Makes Clear that Noncitizens Who Receive Health or Other Benefits to which they are Entitled Will Not Suffer Harmful Immigration Consequences," HHS.gov, September 8, 2022, available at https:/Awww.hhs.gov/about/news/2022/09/08/ new-rule-makes-clear-noncitizens-who-receive-health-or-other-benefits-which-they-are-entitled-will-not-suffer-harmful-immigration- consequences.hitml. [FN36] . Weber, Andrew, "Texas (again) has the highest uninsured rate in the country," KUT 90.5, September 21, 2022, available at https:// www.kut.org/health/2022-09-21 /texas-again-has-the-highest-uninsured-rate-in-the-country. [FN37] . Press release, "ROSEN, COLLINS, LEE, HUDSON BIPARTISAN, BICAMERAL MOBILE HEALTH CARE ACT HEADS TO PRESIDENT'S DESK," Jacky Rosen U.S. Senator for Nevada, September 29, 2022, available at https:// www.rosen.senate.gov/2022/09/29/rosen-collins-lee-hudson-bipartisan-bicameral-mobile-health-care-act-heads-to-presidents-desk/. [FN38] . Stoddard, Martha, and Henry J. Cordes, "Expanded Medicaid leaves fewer Nebraskans without health coverage," Longview News- Journal, September 27, 2022, available at https://www.news-journal.com/expanded-medicaid-leaves-fewer-nebraskans-without-health- coverage/article_3f97e5a8-fc8b-59a7-b745-7 7cf82a5cb27.html#1. [FN39] . Shryock, Todd, "Health insurance coverage is up, but many still uninsured or underinsured," Medical Economics, October 12, 2022, available at https:/Awww.medicaleconomics.com/view/health-insurance-coverage-is-up-but-many-still-uninsured-or-underinsured. [FN40] . Ollove, Michael, "Many Patients Can't Afford Health Costs Even With Insurance," PEW, October 7, 2022, available at https:// www.pewtrusts.org/en/research-and-analysis/blogs/stateline/2022/10/07/many-patients-cant-afford-health-costs-even-with-insurance. [FN41] . Press release, "Seniors to be Protected from Health Coverage Gaps Following Senator Hassan and Colleagues' Call," Maggie Hassan Unites States Senator for New Hampshire, November 1, 2022, available at https://www.hassan.senate.gov/news/press-releases/ seniors-to-be-protected-from-health-coverage-gaps-following-senator-hassan-and-colleagues-call. [FN42] . Press release, "HHS Continues Biden-Harris Administration Progress in Promoting Health Equity in Rural Care Access Through Outpatient Hospital and Surgical Center Payment System Final Rule," HHS Newsroom, November 1, 2022, available at https:// www.cms.gov/newsroom/press-releases/hhs-continues-biden-harris-administration-progress-promoting-health-equity-rural-care- access-through. [FN43] . 'Annual Family Premiums for Employer Coverage Average $22,463 This Year, with Workers Contributing an Average of $6,106, Benchmark KFF Employer Health Benefit Survey Finds," KFF, October 27, 2022, available at https://www.kff.org/private-insurance/ press-release/annual-family-premiums-for-employer-coverage-average-22463-this-year/. Produced by Thomson Reuters Accelus Regulatory Intelligence 27-Jun-2023 THOMSON REUTERS © 2023 Thomson Reuters. No claim to original U.S. Government Works. -35-