I've included the transcript below, but words can't accurately describe the tone of voice or the body language of Grassley in the actual video, so I'll just urge everyone to watch it.

WOMAN: "What is your plan to keep millions of Americans like myself covered? Those of us with pre-existing conditions, people who are on their parents insurance, and again, people like myself who need life-guaranteeing medication? We could lose our insurance and I'd probably be dead in 2 months."

GRASSLEY: "Well, there's a...there's a lot of, uh...and she's asking only because the courts may declare [the ACA] unconstitutional. Now, I don't think that the courts are going to declare it unconstitutional..."

WOMAN: "You voted seven times to repeal it."

GRASSLEY: (pause) "Yes."

WOMAN: "Why? What are you going to do for people on the ACA?"

Just a few minutes ago I noted that the state of Oregon is once again strongly considering taking a second crack at establishing their own, fully state-based ACA exchange after spending the past five years piggybacking on top of HealthCare.Gov.

Well, the Oregon State Public Interest Research Group just published an extensive report in which they urge the state to do just that...along with several other key changes which I also strongly agree with:

Steps like a mandate for Oregon residents to buy health insurance and relief for exchange customers who earn too much to receive tax credits under the Affordable Care Act could help reverse premium hikes that have shot up amid attempts by the Trump administration to roll back the law, OSPIRG, the Oregon State Public Interest Group, argued in a report released Wednesday.

There are 12 states which operate their own full ACA exchanges, including their own board of directors, marketing budget, bylaws and tech platform for their enrollment website. 34 states have offloaded just about all of that to the federal exchange, HealthCare.Gov.

And then there are five states which are in between: They have their own state-based exchange...but their tech platform is basically piggybacked onto the federal exchange: Arkansas, Kentucky, Nevada, New Mexico and Oregon.

Nevada and Oregon had such major technical problems at launch that they scrapped their sites after the first year and moved to the Mothership. Hawaii also scrapped their exchange site after the second or third year, but they shut down their entirestate-based exchange and moved everything to HC.gov). Nevada announced that they're giving their own full exchange a second shot this November.

"Medicaid Work Requirements" have been in the news a lot over the past two years as the Trump Administration has given states the go-ahead to start imposing increasingly draconian, humiliating and ineffective work requirements for low-income people to avoid losing healthcare coverage.

For the most part, though, the work requirement bills have at the very least been restricted to ACA expansion of the Medicaid program to "able-bodied" adults earning up to 138% of the Federal Poverty Line (roughly $17,000/year for a single adult or $23,300 for a couple without minor children).

Today, Joan Alker of the Georgetown University Health Policy Institute Center for Children & Famlies reports that the Florida House of Representatives is planning on taking the cruelty even further:

URGENT: On Thursday, the Florida House will take up the harshest Medicaid work reporting requirement bill that I’ve EVER seen. As many as 100,000, mostly mothers, could lose their health insurance. https://t.co/64uRz23Puk

(sigh) I wrote about "Farm Bureau Plans" several times last year. They've been widespread in Tennessee for a long time, and are a big part of the reason for the state's high ACA premiums (TN doesn't have the highest premiums, but they're definitely near the top of the list). Here's the description of typical Tennessee "Farm Bureau" plans:

Traditional plans require medical underwriting that may affect eligibility and rates. Medical information will be requested for any person over the age of 40 and children 25 months and under; medical records may also be requested if any health condition on the application is marked “yes.” Any fees for obtaining medical information will be at the applicant’s expense.

Underwriting guidelines regarding particular conditions may necessitate a benefit exclusion rider, a member exclusion rider or an adjusted rate for coverage. There will be a 6-month or 12-month waiting period for pre-existing conditions, depending upon the plan chosen.

 

Nearly two years ago, I noted that the then-CEO of Aetna, Mark Bertolini, gave an unexpected response to to a question about single payer healthcare in a private meeting to Aetna employees:

Single-payer, I think we should have that debate as a nation. But let me remind everybody that Aetna was the first financial intermediary for Medicare. We cut the first check for Medicare in 1965 to Hartford Hospital for $517.57.

The government doesn’t administer anything. The first thing they’ve ever tried to administer in social programs was the ACA, and that didn’t go so well. So the industry has always been the back room for government. If the government wants to pay all the bills, and employers want to stop offering coverage, and we can be there in a public private partnership to do the work we do today with Medicare, and with Medicaid at every state level, we run the Medicaid programs for them, then let’s have that conversation.

From January:

via Dave Anderson of Balloon-Juice:

The Notice for Benefit and Payment Parameters (NBPP) is an annual rule that the Center for Medicare and Medicaid Services (CMS) puts out. NBPP is the operational rule book for the Affordable Care Act. It determines what types of plans can be offered, how pricing is determined, when do things need to be approved, and whether or not Silver Loading is allowed or a Broad Load is required. This is all big stuff for the ACA markets.

The annual NBPP is supposed to be released sometime in November. Last year it wasn't released until December. This year it's mid-January and still no NBPP, although it's supposedly trudging along slowly

There seems to be something in the air this week...or perhaps it just takes roughly 3 months from the time a new legislative session starts for the first legislation to work its way through the process. Whatever the reason, Washington, Connecticut and now Nevada have all made major moves towards codifying ACA patient protections at the state level in the even the ACA itself is repealed:

The Nevada Senate has passed a bill that would enact state-level health care protections for people with pre-existing conditions.

State Sen. Julia Ratti says the legislation aims to bring about protections that are already in place under the Affordable Care Act. The Democrat told lawmakers last month that people are worried about their health care access.

She says Nevada should make sure these protections are in place at the state level if the federal provisions are rolled back.

State senators approved the measure on Monday in a unanimous vote.

The measure stipulates that insurers cannot deny a person health care coverage due to a pre-existing condition.

Hot on the heels of Washington State locking in pretty much every "Blue Leg" ACA protection in a single bill today, the Connecticut state House of Representatives passed their own bill covering some ACA protections (via CT News Junkie):

Connecticut’s House of Representatives voted Wednesday to strengthen state health insurance laws by making sure residents with pre-existing conditions are protected.

House Bill 5521 passed unanimously by a 146-0 vote, and now goes to the Senate.

Well, now. I guess Connecticut Republicans are smarter than Congressional Republicans, anyway...

I don't know if I'm just asleep at the wheel when it comes to healthcare happenings in Washington State lately, but this one caught me by surprise as well:

Today I signed a bill that protects Affordable Care Act health care insurance practices in WA state. This bill assures Washingtonians that regardless of what happens in D.C., we’re protecting your access to care here here at home. #waleg #ACAhttps://t.co/e3g35Fch68

— Governor Jay Inslee (@GovInslee) April 17, 2019

From the official press release:

Combined, the Medicaid and CHIP programs have around 72.5 million Americans enrolled in them as of December 2018. However, the vast majority--over 80% of them--are actually enrolled in privately managed Medicaid programs. Managed Care Organizations (MCOs) are private health insurance companies which states contract with to handle the administration and management. In some cases this works out reasonably well. In others...not so much:

UnitedHealthcare is pulling out of Iowa's private Medicaid management program

More than 425,000 poor or disabled Iowans will soon have to switch health insurance carriers. 

UnitedHealthcare, which manages health care for more than two-thirds of Iowans on Medicaid, is leaving the market, Gov. Kim Reynolds’ office announced late Friday afternoon.

Montana didn't expand Medicaid under the Affordable Care Act until January 2016, and when they did so, the legislation was written with an automatic sunset date of June 30, 2019 unless it's expanded beyond that. Unfortunately, the ballot proposal to make Medicaid expansion permanent failed last November, which put the issue back in the hands of state lawmakers.

The good news is that the Montana state legislature did indeed finally vote to extend the program, which covers around 96,000 people, this week. The bad news is...well:

The bill to continue Medicaid expansion in Montana passed out of the state Senate Tuesday after teetering on the edge of a deadline for end of session negations.

via the Lexington Herald-Leader:

Colorado's Senate advanced another piece of Democratic Gov. Jared Polis' health care agenda on Tuesday by tentatively endorsing a study on creating a state-run health insurance option.

The bill would direct state agencies to recommend a plan that would compete with existing private insurance plans and those offered on Colorado's health care exchange. Another Senate vote sends the study bill to the governor. It's already cleared the House on a bipartisan 46-17 vote.

On the surface, this sounds pretty much like the state-level Public Option bill which has quietly been rushed through the Washington State legislature over the past few weeks. Unlike the Washington bill, however, it looks like the Colorado legislature is covering a few more bases...particularly funding:

I've written several times over the past few months about the confusion regarding how much of an impact on the private insurance industry the move to a universal, 100% publicly-financed single payer healthcare system would have.

Most recently I noted that not only would the latest versions of the House and Senate "MFA" bills expand their reach even further by adding in Long-Term Services & Support (thus legally denying private insurers yet another range of services that they'd be legally allowed to duplicate), but in an interview ahead of the rollout, Bernie Sanders himself stated point-blank that private health insurance companies would be "reduced to nose jobs" and the like (which is of course the whole point).

Back in January, 2nd-term Washington Governor and Democratic Presidential candidate Jay Inslee jumped fully onboard the Public Option train:

Inslee proposes ‘public option’ health-insurance plan for Washington

The proposal, which Inslee said is the first step toward universal health care, is geared in part to help stabilize the exchange, which has wrestled with double-digit premium increases and attempts by Republicans in Congress and President Donald Trump to dismantle the Affordable Care Act.

...The proposal would have the state Health Care Authority contract with at least one health-insurance carrier to offer qualified health coverage on the Washington Health Benefit Exchange, according to a summary of the proposal.

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