The GOP Plan also would allow states to adopt work or education and training requirements for non-disabled Medicaid enrollees and to use Medicaid dollars to provide defined-contribution benefits in the form of premium assistance or a limited benefit to enrollees who are working or preparing for work. States would be allowed to set“ reasonable and enforceable” premiums for nondisabled adults and could require these individuals to use premium assistance without a requirement for wrap-around services. States could also use these dollars to help offset cost-sharing in an employer plan.
Clinton would maintain the existing federal funding structure for Medicaid, but has stated she will also offer incentives, such as allowing states to receive a 100 percent federal match for their expansion population for the first three years of expansion, regardless of when a state chooses to expand. The ACA only authorized the 100 percent match for calendar years 2014–2016. Clinton would also work with governors to expand Medicaid in every state, and invest $500 million per year on a campaign to facilitate enrollment of eligible individuals into both Medicaid and marketplace coverage.
Health Insurance Market
Both political parties have proposed changes to the health insurance markets across the country to address the cost of health insurance and to increase competition.
A public option. In addition to maintaining the ACA, Clinton has proposed the creation of a “public option” health plan that would compete with plans offered by private insurers on the ACA’s online insurance marketplaces.
Purchase of health insurance across state lines. Both Trump and House Republicans are proposing to modify existing laws that prohibit the sale of health insurance across state lines.
To date, five states have enacted legislation allowing insurers authorized in other states to issue policies in their states. Critics, including consumer advocates, argue that states effectively would lose their ability to regulate their own insurance markets and that consumers may not benefit from purchasing plans sold from out-of-state insurers who may have fewer local providers in their networks.
The GOP Plan also includes a number of other proposals related to health insurance, including:
Tax treatment for employer-sponsored insurance. There would be a cap on the dollar amount that individuals are allowed to exclude from their gross income for the value of their employer-sponsored insurance, rather than allowing the full value to be excluded as is currently permitted.
Expanded opportunities for risk pooling. Small businesses would be allowed to band together to offer plans, known as association health plans (AHPs), so small businesses could negotiate with health insurers for lower prices and health plans that do not contain the benefits required by their state’s laws. Individuals would be allowed to come together to purchase coverage through individual health pools (IHPs) that would operate similar to AHPs.
Many states have existing laws regarding the operation of AHPs in the state, which may be impacted by any federal AHP legislation. In Kansas, there are very few association health plans currently operating, and it is not clear what the impact would be on the state’s insurance market if large numbers of small businesses chose to offer AHPs and were permitted to offer products that do not comply with the mandated benefits required understate law.
Self-insurance by employers. This provision would maintain current federal law that allows employers to self-insure their employees, along with the use of stop-loss insurance, including ensuring that stop-loss insurance is not defined as “group health insurance,” which could make it subject to additional federal or state regulation. Self-insured plans are currently subject to federal regulation as Employee Retirement Income Security Act (ERISA) benefit plans but are not subject to state insurance regulation.
Expanding Coverage Options and Protecting Consumers
Trump, House Republicans and Clinton have all offered a number of proposals aimed at expanding health insurance coverage options for Americans and protecting individuals using health insurance to access care.
Health Savings Accounts (HSAs). Both Trump and House Republicans promote the use of HSAs to pay for certain medical expenses. Trump has proposed allowing HSAs to accumulate and become a part of an individual’s estate, which could be passed to heirs with no tax penalty, and used by any family member without penalty.
House Republicans are proposing to increase the maximum contribution to an HSA. The GOP Plan also supports expansion of the use of health reimbursement accounts (HRAs), funded by employers, which employees could use to purchase individual coverage.
A health care “backpack.” In addition to HSAs and HRAs, the GOP Plan proposes the creation of a health care “backpack” that would include a monthly universal, advanceable, refundable tax credit, adjusted for age, that could be used to help pay for a typical “pre-ACA health plan” or to pay for other health care expenses, such as over-the-counter medication or dental and vision care.