The NCSL Blog


By Haley Nicholson

Since last summer there has been a lot of discussion about health insurance markets and premiums at the federal level, notably, cost sharing reduction (CSR) payments and reinsurance programs.

In this Jan. 31, 2017, file photo, Senate Health, Education, Labor and Pensions Chairman Lamar Alexander, R-Tenn., accompanied by ranking member Patty Murray, D-Wash., speaks during a hearing on Capitol Hill.(Photo: Alex Brandon, AP)CSR payments and reinsurance policy proposals have found themselves in a state of limbo on Capitol Hill.

Senators Lamar Alexander (R-Tenn.) and Patty Murray (D-Wash.), pictured at left, introduced legislation that would reinstate CSR payments to ensure health insurance companies continue to participate in more state marketplace plans and keep down premiums.

The legislation also would provide support and increase state flexibility to create reinsurance programs. President Donald Trump’s support for the legislation, however, has wavered and is one of the reasons it has failed to move.

Some senators have also attempted to include these programs in other legislation, and came close to getting them included in the recent passage of Congress’ 2018 Omnibus bill. However, the deal fell through after Senate Democrats could not agree to the inclusion of reproductive health funding restrictions being attached to CSR payments.

CSR payments were implemented under the Obama administration to help insurers participating in state health exchange marketplaces to offset the costs of covering lower income patients who need high cost care. Last fall, the Trump administration decided it would stop making CSR payments.

Some states and insurers anticipated this could happen and planned to set premiums without including any future CSR payments. This resulted in some states increasing the costs of marketplace Silver plans so that the most affordable plans (Copper plans) would still be accessible to low income patients while keeping insurers in the marketplace. Meanwhile, health insurance groups continue to push back on Congress to reinstate CSR payments, but movement has stalled.

Reinsurance programs are in a similar state. Reinsurance programs can be implemented through 1332 waivers. These waivers were established under the Affordable Care Act (ACA) and allow states to set up insurance programs where states and the federal government share financial risk in providing care to high-risk patients.

To date Alaska, Minnesota, Oregon and Hawaii are the only states that have been approved for 1332 waivers. Last year, Iowa and Oklahoma submitted applications for reinsurance waivers but wound up withdrawing them after it was signaled that 1332 waivers would likely not be approved by the administration.   

It appears future congressional action on CSR payments and reinsurance programs are all but done until after midterm elections. In the meantime, states will continue to pursue their own options to ensure their constituents are not left wondering where they will turn for coverage, or worry about how high their premiums could go.

Haley Nicholson is a policy director, health, in NCSL's State-Federal program based in Washington, D.C.

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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.