Planning for the Future

This report has highlighted that with an SBM, Maine can build on its successful embrace of the ACA, which most recently includes expanding Medicaid. The State would be uniquely situated to advance effective marketplace policies, ranging from longer open enrollment timelines to more robust connections to MaineCare. Another key asset of an SBM is the opportunity to anticipate and leverage future opportunities for marketplace innovation, particularly as the federal health policy landscape shifts.

As Maine officials engage in the procurement, implementation, and maintenance of the SBM eligibility and enrollment system, we recommend the State prioritize platform capacity to adapt to future policy innovations.

This section first outlines the federal policy environment following the November 2020 election and its implications for Maine’s marketplace. This is followed by an analysis of policy opportunities to improve affordability and expand coverage in light of this new federal policy environment. We conclude our analysis by outlining our recommendation to build out a marketplace platform with nimble eligibility and enrollment structures, which would provide the State the flexibility to pursue policies discussed in the preceding section.

Background

President Joe Biden has demonstrated an eagerness to build on the ACA, centering the landmark health law in his campaign messaging158 and advancing policy proposals bolstering the ACA.159 President Biden has also signaled his pro-ACA policy intentions by nominating Xavier Becerra, who has a history of defending the ACA in court, for Secretary of Health and Human Services.160 The federal legislative landscape is murkier and indicates a narrower path for significant legislative health reforms in the near future.

Regulatory/Administrative Opportunities

Given existing electoral and institutional constraints, in the immediate term the new administration will likely make its mark on the marketplaces through administrative and regulatory policymaking. The Biden administration will likely prioritize work to unwind recent policy changes from the Trump administration, while also considering which longer-standing rules to roll back through the rulemaking process. For instance, one rule that the Biden administration may be interested in pulling back is the Trump administration’s latest proposed 2022 Notice of Benefit and Payment Parameters. If ultimately implemented, a number of provisions in this rule could undermine the goals of SBMs, including a new requirement for SBMs to conduct burdensome pre-enrollment verifications for SEPs.161

The Biden administration could also proactively advance their priorities without Congressional involvement by leveraging their waiver authority. In particular, the Biden administration will likely be eager to work with states to use 1332 waiver flexibilities to cover new groups, improve affordability, or provide additional health benefits. Indeed, the Biden administration is expected to work closely with states to identify opportunities that align with both state and federal priorities. For example, the Biden administration could leverage 1332 waiver authority to advance coverage expan-

sions such as Medicaid buy-in or state-tailored

public options. The new administration could facilitate such innovations by expanding its interpretation of the 1332 waiver’s budget neutrality window,162 loosening this financial constraint by allowing states to instead point to long-run savings for the federal government given that public option plans enjoy lower reimbursement rates than commercial marketplace plans. When evaluating state-based public option proposals in the future, Maine could consider how states with similar marketplace dynamics have assessed targeted Medicaid buy-in proposals. One such state is New Mexico, which has grappled with the implications of a public option given a small marketplace population and lower-than-average benchmark premiums.163 The Biden administration could also leverage regulatory policymaking to expand access to health care for both undocumented and documented immigrants. Among the demographic groups that could benefit from actions on this front are the more than 2,000 migrant farmworkers who live and work in Maine, the majority of whom are H-2A visa holders or undocumented, as highlighted by a key stakeholder.164 The new administration could classify Deferred

Action as Childhood Arrivals (DACA) recipi-

ents as lawfully present and therefore eligible for APTCs, thereby also ensuring coverage opportunities for DACA recipients. Even more impactful, the Biden

administration could also repeal the public charge rule, which was expanded under the Trump administration to include Medicaid determinations for immigrants seeking permanent citizenship status and which had a chilling effect on immigrants qualifying for marketplace subsidies—despite the fact that subsidies are not within the scope of determinations.165 This could have significant implications for both MaineCare and marketplace enrollment, folding into the risk pool a new population of consumers who data suggest might be younger—and thus would likely be lower utilizers of health care—than the general population.166

Legislative Opportunities

While major legislative changes appear less likely in the immediate future, political dynamics can nonetheless shift in subsequent election cycles. Combined with the potential for sweeping change through Congressional actions, this means that legislative opportunities still deserve careful consideration.

With Democrats now in control of Congress, they can likely pursue a legislative agenda focused on building on the existing infrastructure of the ACA. President Biden’s campaign platform167 and the House-introduced Patient Protection and Affordable Care Enhancement Act168 provide a useful roadmap of likely priorities. Congress could increase the generosity of APTCs by reducing the percentage of income paid to premiums at all income levels. For instance, under the ACA Enhancement Act those with incomes between 100 and 150% FPL would be eligible for no-premium coverage, with the highest premium percentage capped at 8.5% of income for higher earners, including those earning above 400% FPL. Congress could also improve marketplace affordability by eliminating the subsidy eligibility cliff and allowing households of all income levels to qualify for tax credits. While these legislative policy changes would be driven at the federal level, they would directly impact Maine’s marketplace platform. President Biden could also work with Congress to lower the Medicare eligibility age to include Americans ages 60 to 64. Such an expansion would increase Medicare enrollment by 32% in 2030, 33% in 2040, and 34% in 2050, assuming all newly eligible people opt to enroll.169 This proposal would surely face opposition from hospital and provider groups in the health care community. In our interviews, for instance, the Maine hospital community expressed significant concern over a more robust public payer role with lower reimbursement rates than those of private carriers. Maine may also want to consider this policy’s implications for the marketplace risk pool. The stakeholder interviews highlighted that many retired Mainers just under Medicare eligibility age use the marketplace to bridge coverage between employer-sponsored insurance and Medicare, meaning such a policy could siphon off marketplace enrollees. A Biden administration with a Democratically-controlled Congress might also pursue a federal public option. This public option could be offered through the health insurance marketplaces, whether state-based or federally-facilitated, and as an option for those also considering employer-sponsored insurance. The Biden proposal could also auto-enroll those with incomes up to 138% FPL in non-expansion states, while expansion states like Maine would have the choice of keeping individuals on Medicaid or switching them to premium-free public option plans.170 While this proposal would likely face significant stakeholder and political opposition even under a Democratically-controlled Congress, Maine should nonetheless consider both the disruptive and promising implications of a federal public option offered on the marketplace. The next section describes our recommendation for how the State can prepare for and leverage future policy opportunities, considering both impacts on consumers and state feasibility. Recommendation: In the procurement, implementation, and maintenance of the SBM eligibility and enrollment system, prioritize platform capacity to adjust the inputs for the rules engine to adapt to future policy innovation.

Given the potential for future policy changes, it is important that the State considers how the SBM technology platform can adapt quickly to new rules surrounding eligibility and enrollment. Maine should ensure that the vendor procured for developing the SBM technology platform builds flexibility into the system. The SBM platform RFP already incorporates provisions that can make this flexibility possible, meaning that whether a nimble marketplace is developed will largely depend on the process of implementing and maintaining the SBM moving forward.

The State should ensure that the vendor builds a rules engine with adjustable inputs that, on the back end, allows DHHS to adapt the state platform to future changes in eligibility criteria. This specific recommendation builds on Maine’s criteria in the RFP that the platform should allow for “modular integration of eligibility and enrollment functions with minimal changes to the solution’s codebase.”171 Instead of hard-coding the rules engine and making it difficult to adjust, a flexible approach would ensure built-in workarounds for DHHS when adjustments are needed. Such resiliency measures should also protect the rules engine against potential glitches in the event that eligibility criteria are changed in the future. As an example, Washington’s Medicaid system experienced significant backlogs during its first OEP in 2013 and 2014. This was due, in part, to the rules engines not accurately incorporating eligibility requirements and an inability to read complex data relating to household composition.172 Resiliency measures are thus central to this recommendation. Our conversations with enrollment assisters underscored the importance of a straightforward and reliable enrollment platform for consumers. A platform that avoids such glitches would advance this objective while helping the State avoid frequent and expensive IT fixes whenever an eligibility change occurs.

Consumer Impact

By prioritizing the development of a flexible eligibility and enrollment platform, Maine is positioning itself to build an SBM able to respond to policy opportunities and responsive to the needs of Mainers. A nimble marketplace can act as a vehicle to advance future policies expanding coverage, increasing affordability, and narrowing health disparities. Moreover, the added layer of flexibility will ensure that fewer Mainers experience glitches or are not enrolled properly following changes in eligibility criteria, facilitating a smoother consumer experience.

State Feasibility

The RFP for the SBM technology platform vendor already allows for some of this flexibility in building, implementing, and maintaining the system. This recommendation encourages DHHS to play an active role in prioritizing platform flexibility with the vendor, which will require the use of time and human resources. However, since Maine will maintain at least a five-year contract with the vendor, this ongoing relationship can create touchpoints for DHHS staff to request changes in parts of the platform, such as the rules engine.

With regard to oversight, the independent verification and validation stage of the vendor contract process will enable Maine to assess its satisfaction with the level of flexibility and resiliency built into the system. The enabling statute includes the appropriation for this independent verification and validation step.173

Lastly, this recommendation would garner broad support among key carrier, provider, and advocacy stakeholders. These flexibilities could advance policies increasing the number of enrollees on carrier plans, lower uncompensated care costs for providers while expanding the volume of commercial reimbursements, and increase coverage levels for consumers.