November 22, 2017
Seema Verma, Administrator
Centers for Medicare & Medicaid Services
Department of Health and Human Services
Attention: CMS–9930–P
P.O. Box 8016
Baltimore, MD 21244–8016
Dear Administrator Verma:
Thank you for the opportunity to provide comments on the Patient Protection and Affordable Care Act Notice of Benefit and Payment Parameters 2019. The National Center for Health Research (NCHR) analyzes scientific and medical data and provides objective health information to patients, providers, and policymakers. We do not accept funding from the drug or medical device industry, so we have no conflicts of interest.
This is an extensive document, and we will only focus on 4 issues.
As HHS further refines the Benefit and Payment Parameters and implements its proposed changes, we provide the following recommendations:
#1. We urge you to reject the proposed changes to the Navigator Program (part 155). The proposed changes would weaken the effectiveness of the program. It is imperative that at least one of the two (or more) Navigator entities represent a not-for-profit community and/or consumer perspective. Such entities are better equipped to provide unbiased advice and information, are more attuned to consumer needs, and have a better understanding of the unique opportunities and challenges within the respective community. Community-based groups have the inherent incentive to promote better outcomes for all community members, rather than focusing on the number of enrollees they can list in their metrics. In addition, we strongly believe that Navigators must be physically present for one-on-one meetings in the geographic region. Navigators must be accessible to all types of consumers, including those with limited access to the internet, insufficient bandwidth, or limited computer skills, so that they can successfully enroll. Having the option of a face-to-face meeting will provide many more individuals and families with the opportunity to make informed consumer healthcare decisions.
#2. We agree with expanding eligibility for special enrollment (part 155). We suggest finalizing the proposal to permit pregnant women covered on CHIP to become eligible for special enrollment. The post-pregnancy period is a critical time in a woman’s life when she desperately needs access to vital health services, such as prevention and treatment regarding blood clots, infections, lactation issues, and postpartum depression. Expanding access can support women and children’s health in the short-term and the long-term.
#3. We strongly oppose high risk pool adjustments (part 153). High risk pooling is unethical and places undue financial burden on Americans with more severe, lifelong or catastrophic health conditions. Asking that 60 percent of medical expenses come out of the pocket of this vulnerable population is bad policy. This type of “adjustment” is a euphemism for insurance discrimination for a pre-existing medical condition. We agree that the risk the insurance company may face with such enrollees is high; however, that risk is attenuated through the transfer adjustment. We strongly urge that CMS propose other means to reduce costs without denying very ill or chronically ill Americans the right to fair healthcare access.
#4. We urge that quality measures include social risk factors (part 156). The measures of quality should include the likely social determinants of health, including race/ethnicity, socioeconomic status, geographic location, etc. In order to reduce health disparities, Qualified Health Plans (QHP) should be rated on their inclusivity, as measured by the diversity of their enrollees on these social determinants. For example, the Quality Rating System (QRS) includes an item on controlling blood pressure. It is well known that ethnicity/genetic variation (particularly African American) plays a role in blood pressure control. Therefore, QHPs which enroll a greater proportion of African Americans with hypertension may not meet pre-specified quality metrics, unless social determinants of health are factored into the QRS.
Thank you for your consideration of the above recommendations. We urge you to focus on strategies which address the health needs of all Americans and provide opportunities for more access to quality care. We are particularly concerned that changes to the Navigator program would reduce enrollment in ways that could be detrimental to the health of many Americans. The above recommendations will enable HHS to more effectively carry out its mission and responsibilities to improve the health of all Americans.
Sincerely,
Diana Zuckerman, PhD
President
National Center for Health Research