The NCSL Blog


By Richard Cauchi

Could 4 million Americans drop health insurance this coming fall? Could new “skinny” health plans appeal to consumers who rarely see a doctor? Can a hard-to-explain new waiver lower your premiums?

Now that the new federal tax cut law has altered a core provision of federal health law by repealing the individual mandate, what’s next?

NCSL members from across the nation gathered in San Diego before the holidays to learn about breaking news changes and discuss common sense and innovative state strategies. An impressive array of hands-on experts, matched with legislative health leaders, learned from each other and had little time to visit the Pacific beach.

National experts shared their views about the effects of numerous federal changes to insurance provisions, including the hold on cost-sharing reductions, the shortened timeframe to sign up for coverage under the federal health insurance exchange, President Donald Trump’s executive order to allow purchase of insurance plans across state lines, and the tax package’s repeal of the individual mandate.

Presenters included:

  • John Bertko, Covered California
  • Sara Collins, The Commonwealth Fund | Presentation
  • Kevin Lucia, Georgetown University Center on Health Insurance Reforms
  • North Dakota Representative George Keiser (R)
  • Maryland Delegate Dan Morhaim (D)
  • Karen Shields, formerly with Centers for Medicare and Medicaid Services until October 2017 and now with Serco Americas
  • Myra Simon, America’s Health Insurance Plans | Presentation
  • Hemi Tewarson, National Governors Association

The Takeaway Messages

For the members who didn’t travel west in mid-December, NCSL health staff gathered a collection of e-documents designed by speakers for legislative use in 2018 sessions.

  • Exchange Enrollment Nationwide. Collins provided an updated snapshot of consumer enrollment by state for 2018 with weekly numbers visibly higher than in 2014-17. The  Trump administration’s decision to shorten enrollment by 45 days, the elimination of cost-sharing reduction (CSR) payments and cuts in federal advertising and navigator funding were new factors. 
  • As a supplement, NCSL has posted a 50-state table with final day statistics for all federally run marketplaces, including many larger than expected state results, including previous year results. For example, Florida totaled 1,731,275, Illinois ended at 339,740 while 1,130,594 Texans enrolled. Each state figure is a higher total than the 45-day enrollment in 2017 or 2016.
  • Lessons from California-Exchange. Bertko’s message: “We do a lot of marketing and outreach, 10 times what the federal government did. People buy because of ‘free money,’ otherwise known as subsidies; this effect overwhelms the importance of the individual mandate. But you have to sell it.”
  • States and Insurers. Simon: Multiple factors will continue to affect access to health insurance throughout 2018. (see accompanying graphics)
  • State Section 1332 Waivers explained by  Shields and Lucia. Takeaway: “Three of the four 1332 waivers that have been approved to date support state requests to improve and stabilize the insurance market and lift up the risk pools (Alaska, Minnesota and Oregon). The more complicated waivers have asked for changes that require a technical update to the CMS infrastructure.”
  • State Options to Protect Consumers and Stabilize the Market: Responding to Trump’s executive order on Association Health Plans. Takeaway message: “[Until now] associations with individual members could not meet the definition of a large employer plan because individual members are not considered employers under federal law.”
  • Health Executive Order Demystified. Lucia’s message: These plans potentially will “include individuals and the self-employed while pre-empting state regulation of self-funded multi-employer welfare arrangements (MEWAs).”

Graphic showing additional cost of health insurance for a 40-year-old following passage of 2017 federal tax legislation

NCSL maintains resources on health insurance and coverage online.

Richard Cauchi is an NCSL program director in Health

Email Richard

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About the NCSL Blog

This blog offers updates on the National Conference of State Legislatures' research and training, the latest on federalism and the state legislative institution, and posts about state legislators and legislative staff. The blog is edited by NCSL staff and written primarily by NCSL's experts on public policy and the state legislative institution.