CMS pushing Sec 1332 waivers for high risk pools/reinsurance

CMS Checklist For State 1332 Waivers Focuses On High-Risk Pools, Reinsurance

By Timothy Jost
Health Affairs Blog, May 12, 2017

On May 11, 2017, the Centers for Medicare and Medicaid Services and the Department of the Treasury released a checklist for state 1332 innovation waiver applications. Following up on Health and Human Services Secretary Price’s letter to state governors of March 13, 2017, the checklist specifically focuses on state 1332 proposals to support high-risk pools or reinsurance programs.

The checklist restates the procedural requirements that states must meet under the current 1332 rules, such as posting a notice of the waiver proposal and accepting comments for at least 30 days, holding two public hearings, and consulting with Indian tribes where relevant.

Most elements in the checklist, however, describe specifically what information states must submit with applications for a 1332 waiver involving a reinsurance or high-risk pool program. While states must generally document state legislative authority to operate a 1332 waiver program, a state seeking a waiver to operate a high-risk pool or reinsurance program must establish that the legislation makes the program contingent on 1332 waiver approval or that the program will only become operational if the waiver is approved.

In sum, the checklist provides a roadmap for states that want to pursue high-risk pool or reinsurance 1332 waiver proposals, indicating again the priority that the Trump administration places on this approach for increasing the affordability of health insurance coverage.

CMS Checklist for Section 1332 State Innovation Waiver Applications, including specific items applicable to High-Risk Pool/State-Operated Reinsurance Program Applications:



By Don McCanne, M.D.

One of the prime drivers of the Affordable Care Act was the inherent flaws in the individual insurance market. As more people with expensive health care problems enrolled in the individual plans, premiums went up and the healthy dropped out, resulting in the “death spiral” of skyrocketing premiums. Insurers countered by limiting benefits, by excluding individuals with preexisting disorders, or by pulling out of markets with higher-cost beneficiaries.

To cover those who had a greater need for care, many states established high-risk insurance pools, but these pools were very expensive. The benefits were quite limited, and the premiums were very high, but they also required large contributions from the states. Think about the fact that the 20 percent of people who had major health problems consumed 80 percent of the health care (the 80/20 rule). Moving 80 percent of the costs for these patient populations into separate pools proved to be far too much for the states, so the pools were severely underfunded. Benefits were spartan, many could not afford the premiums, and intolerable waiting lists were established due to enrollment caps. They were a policy failure.

Yet what does the current Congress and administration want to do about this problem? They have emphasized repeatedly that the leading priority is to make premiums affordable. To do this they would go back to the dysfunctional individual market in which only the healthy were insured, with one technical modification. They would reestablish separate high-risk pools to insure the costly patients, or they would leave everyone in the same risk pool but provide reinsurance to cover the excessive losses resulting from caring for the more expensive patients. In either case, the costs of the pools and/or reinsurance would be very high. Since they want to keep the premiums low these extra costs would have to be paid by the state or by “federal pass-through payments.”

The CMS checklist states, “State-operated reinsurance programs have a demonstrated ability to help lower premiums, and if the state shows a reduction in federal spending on premium tax credits a state could receive Federal pass-through funding to help fund the state’s reinsurance program.” In other words, the federal contribution would be only the amount that they would otherwise be contributing in the form of premium tax credits - a budget neutral solution. This could not possibly fund either a high-risk pool or a reinsurance program for the the most expensive patients. The prior experience with the state high-risk pools has already confirmed that the states, for both political and fiscal reasons, are not capable of funding these pools either.

So all of this talk about federal authorization of high-risk pools and reinsurance programs through Section 1332 waivers is garbage. The current federal government has no intention of funding these programs, but they will authorize them and then sit back and blame the states for failing to implement them properly. Who is harmed by all of this? The patients, of course.

We would not have to worry about the 80/20 rule if everyone were in the same universal risk pool as they would be in a single payer, improved Medicare for all program. Unless our current political leaders suddenly have a miraculous communal epiphany, we need to replace them.