HOUSE BILL 3590 SECTION 1412
SEC. 1412 [42 U.S.C. 18082]. ADVANCE DETERMINATION AND PAYMENT OF PREMIUM TAX CREDITS AND COST-SHARING REDUCTIONS
“CHANGES IN CIRCUMSTANCES.—The Secretary shall provide procedures for making advance determinations on the basis of information other than that described in paragraph (1)(B) in cases where information included with an application form demonstrates substantial changes in income, changes in family size or other household circumstances, change in filing status, the filing of an application for unemployment benefits, or other significant changes affecting eligibility, including (A) allowing an individual claiming a decrease of 20 percent or more in income, or filing an application for unemployment benefits, to have eligibility for the credit determined on the basis of household income for a later period or on the basis of the individual’s estimate of such income for the taxable year; and (B) the determination of household income in cases where the taxpayer was not required to file a return of tax imposed by this chapter for the second preceding taxable year.” (“ACA,” 2010, p. 150).
- Change of income
- A decrease in income by 20%
- Filing an unemployment application
- Determination of household income where the taxpayer was not required to file a tax return the second preceding taxable year (“ACA,” 2010)
- Change of family size or other household circumstances
- Losing job-based coverage
- Losing individual health coverage for a plan you bought yourself
- Loss of eligibility for Medicaid or CHIP
- Loss of coverage through a family member
- Gaining membership into a federally recognized tribe
- New U.S. Citizen
- Leaving incarceration
- Have a baby
- Divorce with loss of coverage
- Death of spouse with loss of coverage
- Moving to a new home in a new zip code (restrictions apply) (“Special,” n.d.)
Proposed Amendment to SEC. 1412 OF H.R.3590
Omit the following: Losing job-based coverage losing individual health coverage for a plan you bought yourself, loss of eligibility for Medicaid or CHIP, loss of coverage through a family member, gaining membership into a federally recognized tribe, new U.S. citizen, leaving incarceration, marriage, have a baby, divorce with loss of coverage, death of spouse with loss of coverage, moving to a new home in a new zip code (restrictions apply) (“Special,” n.d.)
Replace with: is such as that any participant who is unable to obtain healthcare insurance through their employer or spouses’ employer would be eligible to enroll in the marketplace twelve months out to the year without meeting “special circumstances.”
The Patient Protection and Affordable Care Act was signed into law on March 23rd, 2010 (Congress.Gov, 2010). The primary goal of it is to provide affordable health care insurance coverage to those who do not have health insurance offered in their workplace, have a life-changing event, have a pre-existing condition, or are on a limited financial budget. The specific portion of the bill I am proposing a change in the SEC. 1412 of Bill 3590, advance determination and payment of premium tax credits and cost-sharing reductions subheading “Change of Circumstances.” The specific item I’m addressing is open-enrollment. Currently, the enrollment period for the marketplace is November 1st to December 15th of each calendar year I propose to omit the open enrollment period and special circumstances and allow for enrollment anytime during the twelve-month calendar year.
Bloom (2017) reports the average American spends $9596 in healthcare yearly. Often Americans who are on limited incomes do not feel they have the extra money to pay health insurance premiums, or they are in good health and choose not to access healthcare unless necessary. The average emergency room visit cost reported by the National Institute of Health in 2013 was between $1,233 and $2,168 (Debt.org, 2019). Patients could potentially curve this cost if they had the opportunity to enroll anytime for insurance.
I recently had a patient in the emergency department (ED) who was twenty-four years old and experiencing palpitations; he was diagnosed with new-onset atrial fibrillation and hypertension. He does not have insurance. He then was referred to cardiology, and they required an upfront payment of $2500 for an echocardiogram. He told them he did not have the money they advised him that they would not be able to do any additional testing or physician visits until the bill was paid in full for this test and the cardiology consult, subsequently he did not have the screening. Since that time, he has not been able to obtain health insurance. He is taking the risk of not having further complications until he can enroll in the marketplace in November of 2019 (T. Frydendall, personal communication, February 20, 2019). Subsequently, he may end up with complications that cost more to the healthcare system because of the delay in care than he would if he were able to obtain insurance now.
According to the Centers for Disease Control and Prevention (CDC) (2017) “heart disease, cancer and diabetes are responsible for 7 out of 10 deaths and account for 75% of the nation’s health spending” (“Prevent,” 2017, para. 2) and these conditions are preventable. Even if patients do not have insurance for the prevention of diseases, a year-long open enrollment will allow them to seek the care they need preventing a more significant financial burden on themselves and others because if these types of conditions are untreated life-altering events can occur causing disability. This is turn lays the financial burden on the taxpayers.
The primary stakeholder involved in the revision would be the Department of Health and Human Resources (HHS), because of the funding required to operate the various applicable sites. All exchanges are expected to assist consumers with applications, run a website, offer a toll-free call center, organize outreach, and offer education to help consumers make informed decisions (“Health,” 2018). Stakeholders identified in Health (2018) are defined as navigator organizations whose chief function is to offer public education activities and help with enrollment in plans provided via the exchange, state insurance departments, issuers, research and consumer advocacy organizations, professional trade associations and state-based exchanges. Costs for maintaining open enrollment would likely increase because the services would be offered year-round instead of at a designated free enrollment period.
The above stakeholders are likely to be the ones who oppose the proposal because of the cost. In 2018 the HHS reduced spending on advertising by ninety percent compared to 2017 and reduced income support by forty-two percent to navigator organizations. The proposed year, around “open enrollment,” would increase the costs, potentially spending taxpayer money that may not be available. If the proposal were accepted, the risks and benefits of value would have to be compared to identify if the extra money spent increased the number of enrollees and if the enrollees had health conditions that warranted enrollment.
The House of Representatives who passed the bill initially would be who I want to introduce the revision too. However, before that, I would need to seek committee approval from the Ways and Means committee because they are a permanent committee within the House of Representatives and make recommendations on raising revenue, funding my proposal would likely be from taxation (Dictionary.com, 2019). They will help decide if this is a financially feasible amendment.
To gather support for the proposed change, I would want to examine if there is local interest. I could obtain this information by speaking to local organizations such as Kiwanis and the American Legion. If I can gather local support, I would contact my local representatives to collect information regarding any special interest groups and reach out to them. Another avenue of exploration is the major insurance companies such as Blue Cross and Blue Shield, United Health Group, and Anthem; one could contact them and investigate their position on the subject and potentially gain support. I would call attention to the benefits of a yearlong open enrollment, such as an increase in premium-paying customers, a decrease in costs of benefits used, and improvement of one’s reputation in the insurance field.
To reach a large group, I would start locally to help gain support. The first step would be to ascertain if the local newspaper would be willing to run an article about the proposed amendment, who it would benefit, and why. Another avenue to reach many people is Facebook. One could post an easy to read the document with the benefits of the proposal and explain what the amendment is and why it is essential. In introducing my plan to groups, I would inquire if local organizations have a newsletter with an opinion or political section to put an article into raise awareness and support. Using the personal story as above would help gain attention for the need.
Affordable Care Act and Reconciliation Act. (2010). Retrieved from https://www.hhs.gov/healthcare/about-the-aca/index.html
Enroll in or change 2019 plans — only with a special enrollment period. (n.d.). Retrieved from https://www.healthcare.gov/coverage-outside-open-enrollment/special-enrollment-period/
Congress.Gov. (2010). https://www.congress.gov/
Debt.org. (2019). https://www.debt.org/medical/emergency-room-urgent-care-costs/
Dictionary.com. (2019). https://www.dictionary.com
Health insurance exchanges HHS should enhance its management of open enrollment performance. (2018). Retrieved from https://www.gao.gov/assets/700/693362.pdf
HHS.gov. (2017). https://www.hhs.gov/healthcare/about-the-aca/index.html
How Harborview Medical Center made time for nurses’ breaks—and how it paid off. (2016). Retrieved from https://www.advisory.com/daily-briefing/2016/09/28/nurse-breaks
Preventive health care. (2017). Retrieved from https://www.cdc.gov/healthcommunication/toolstemplates/entertainmented/tips/PreventiveHealth.html