Insurance Law Commons^™

Avoiding Pandora’S Box: Why Federal Nondiscrimination Statutes Do Not Prohibit Health Insurance Coverage Exclusions Of Sex-Rejecting Procedures, Rachel N. Morrison

Catholic University Law Review

There is increasing litigation over whether employer-provided health insurance and state Medicaid plans can exclude coverage of procedures for “gender transitions.” Plaintiffs claim that gender-transition coverage exclusions violate the Equal Protection Clause of the Fourteenth Amendment and federal nondiscrimination statutes. While Fourteenth Amendment claims should be foreclosed by the Supreme Court’s holding in Geduldig v. Aiello, nondiscrimination claims require a separate analysis.

This article shows the proper analysis for whether coverage exclusions of transition procedures violate federal nondiscrimination statutes. Looking to the history of coverage exclusion claims, Part I traces sex and pregnancy discrimination claims challenging coverage exclusions of …

Privatized Medicaid: An Incentivized System Of Constant Denials, Hannah R. Courtney

West Virginia Law Review

The Medicaid Program was created to fill the gap of what private insurance would not do—provide vulnerable populations with meaningful access to quality health care—but now it has been thrown into the pitfalls of private insurance. Over the last two decades, there has been a significant rise in states contracting with private Managed Care Organizations (“MCOs”) to provide services to a percentage of their Medicaid enrollees. MCOs now make decisions each year to approve or deny millions of requests for Medicaid coverage of health care services using prior authorization. Until now, the criticisms and fears surrounding privatized Medicaid have largely …

The Reincorporation Of Prisoners Into The Body Politic: Eliminating The Medicaid Inmate Exclusion Policy, Mira K. Edmonds

Articles

Incarcerated people are excluded from Medicaid coverage due to a provision in the Social Security Act Amendments of 1965 known as the Medicaid Inmate Exclusion Policy (“MIEP”). This Article argues for the elimination of the MIEP as an anachronistic remnant of an earlier era prior to the massive growth of the U.S. incarcerated population and the expansion of Medicaid eligibility under the Patient Protection and Affordable Care Act of 2010. It explores three reasons for eliminating the MIEP. First, the inclusion of incarcerated populations in Medicaid coverage would signify the final erasure from the Medicaid regime of the istinction between …

“Waiving” Goodbye To Medicaid As We Know It: Modern State Attempts To Transform Medicaid Programs Through Section 1115 Waivers, Chandler Gray

Washington and Lee Law Review Online

This Note explores recent state efforts to reshape their respective Medicaid programs through Section 1115 waivers. Specifically, this Note looks at states that wish to convert their Medicaid program to a block grant through Section 1115 waivers. Examining the lawfulness of these waivers requires analyzing the language and application of both the Medicaid Act and the Administrative Procedure Act. This Note argues that any use of Section 1115 waivers to implement a block grant program would be a violation of the Medicaid Act and thus unlawful. Further, federal approval of such programs would be deemed arbitrary and capricious. To justify …

Mhpaea & Marble Cake: Parity & The Forgotten Frame Of Federalism, Taleed El-Sabawi

Dickinson Law Review (2017-Present)

No abstract provided.

Executive Power And The Aca, Nicholas Bagley

Book Chapters

As with any law of its complexity and ambition, the Affordable Care Act (ACA) vests in the sitting president broad implementation discretion. The law is not a blank check: in many ways both large and small, the ACA shapes and constrains the exercise of executive power. But Congress has neither the institutional resources nor the attention span to micromanage the rollout of a massive health program. It has no choice but to delegate.

Naturally, both President Obama and President Trump have drawn on their authority to tailor the ACA to their policy preferences. Neither president, however, has been able to …

Sb 106 - Patients First Act, Jasmine Nicole Becerra, Leanne E. Livingston

Georgia State University Law Review

The Patients First Act amends both Title 49 and Title 33 of the Official Code of Georgia Annotated, which allows the state to apply for two federal waivers. One being the Section 1115 waiver to the Social Security Act. The second being the Section 1332 waiver to the Affordable Care Act. Section 1115 waivers apply to Medicaid and may be sought to include a maximum income threshold up to 100% of the Federal Poverty Level. The Section 1332 innovation waiver applies to insurance coverage generally.

Contracting For Healthcare: Price Terms In Hospital Admission Agreements, George A. Nation Iii

Dickinson Law Review (2017-Present)

This article discusses the application of contract law principles to the relationship between hospitals and patients to determine how much patients owe for the health care they receive. For patients who are covered by in-network health insurance the exact nature of the contract created with the hospital usually is not relevant to the patient’s financial obligation because the patient’s contract with the hospital is superseded by the contract between the patient’s health insurer and the hospital. Nevertheless, even in-network patients are financially impacted, via increased insurance premiums, by the contract analysis discussed here, and for the increasing number of patients …

Humanizing Work Requirements For Safety Net Programs, Mary Leto Pareja

Pace Law Review

This Article explores the political and policy appeal of work requirements for public benefit programs and concludes that inclusion of such requirements can be a reasonable design choice, but not in their current form. This Article’s proposals attempt to humanize these highly controversial work requirements while acknowledging the equity concerns they are designed to address. Drawing on expansive definitions of “work” found in guidance published by the Centers for Medicare and Medicaid (“CMS”) and in various state waiver applications, this Article proposes that work requirements be approved for Medicaid (as well as other benefit programs) only if they encompass various …

Humanizing Work Requirements For Safety Net Programs, Mary Leto Pareja

Faculty Scholarship

This Article explores the political and policy appeal of work requirements for public benefit programs and concludes that inclusion of such requirements can be a reasonable design choice, but not in their current form. This Article’s proposals attempt to humanize these highly controversial work requirements while acknowledging the equity concerns they are designed to address. Drawing on expansive definitions of “work” found in guidance published by the Centers for Medicare and Medicaid (“CMS”) and in various state waiver applications, this Article proposes that work requirements be approved for Medicaid (as well as other benefit programs) only if they encompass various …

Reform At Risk — Mandating Participation In Alternative Payment Plans, Scott Levy, Nicholas Bagley, Rahul Rajkumar

Articles

In an ambitious effort to slow the growth of health care costs, the Affordable Care Act created the Center for Medicare and Medicaid Innovation (CMMI) and armed it with broad authority to test new approaches to reimbursement for health care (payment models) and delivery-system reforms. CMMI was meant to be the government’s innovation laboratory for health care: an entity with the independence to break with past practices and the power to experiment with bold new approaches. Over the past year, however, the Department of Health and Human Services (HHS) has quietly hobbled CMMI, imperiling its ability to generate meaningful data …

Medicaid For All?: State-Level Single-Payer Health Care, Lindsay Wiley

Scholarly Articles in Law Reviews & Journals

If single-payer health care is ever to become a reality in the United States, it will very likely be pioneered by a state government, much like Canada’s single-payer system was first adopted in the provinces. Canada’s system operates more like U.S. Medicaid — financed nationally but administered largely by the provinces — than U.S. Medicare. This article describes three basic strategies progressive U.S. state governments are exploring for achieving universal access to high-quality health care and better health outcomes for their residents. First, maximizing eligibility for the existing Medicaid program using matching federal funds. Second, taking up the mantle of …

Small Change, Big Consequences — Partial Medicaid Expansions Under The Aca, Adrianna Mcintyre, Allan M. Joseph, Nicholas Bagley

Articles

Though congressional efforts to repeal and replace the Affordable Care Act (ACA) seem to have stalled, the Trump administration retains broad executive authority to reshape the health care landscape. Perhaps the most consequential choices that the administration will make pertain to Medicaid, which today covers more than 1 in 5 Americans. Much has been made of proposals to introduce work requirements or cost sharing to the program. But another decision of arguably greater long-term significance has been overlooked: whether to allow “partial expansions” pursuant to a state Medicaid waiver. Arkansas has already submitted a waiver request for a partial expansion, …

Covering The Care: Health Insurance Coverage In New Hampshire, Jo Porter, Lucy Hodder

Law Faculty Scholarship

the first in a series of data and policy briefs that seek to inform the current conversations about health reform happening across the state. The first brief uses data from the American Community Survey to provide information about the health insurance coverage landscape in NH.

N.C. Medicaid Reform: A Bipartisan Path Forward, Barak D. Richman, Allison Rice

Faculty Scholarship

The North Carolina Medicaid program currently constitutes 32% of the state budget and provides insurance coverage to 18% of the state’s population. At the same time, 13% of North Carolinians remain uninsured, and even among the insured, significant health disparities persist across income, geography, education, and race.

The Duke University Bass Connections Medicaid Reform project gathered to consider how North Carolina could use its limited Medicaid dollars more effectively to reduce the incidence of poor health, improve access to healthcare, and reduce budgetary pressures on the state’s taxpayers.

This report is submitted to North Carolina’s policymakers and citizens. It assesses …

A Broke(N) System: Comment On The Supreme Court's Decision To Rule On The Equal Access Provision In Douglas V. Independent Living Center, And Its Potential Impact On The Affordable Care Act, Megan Waugh

Journal of the National Association of Administrative Law Judiciary

This comment first provides a historical and legal backdrop of the Medicaid system, the Equal Access Provision and private individuals' enforcement of the Equal Access Provision through litigation in order to analyze the outcome of Douglas in light of the Supreme Court's decision in the Affordable Care Act Case. Then taking that analysis, this article recommends an approach to handle either a cause of action or no cause of action under the Supremacy Clause upon the implementation of PPACA.

Let Fifty Flowers Bloom: Health Care Federalism After National Federation Of Independent Business V. Sebelius, Ann Marie Marciarille

Faculty Works

Conventional wisdom is that the American public does not want to think too long or too hard about Medicaid. Medicaid’s reputation has long been big, complicated, and widely misunderstood. The 2012 presidential election campaign has been much about Medicaid, but Medicaid is a subject we love to talk around. Yet, our next president will be compelled to think and speak explicitly and fluently about Medicaid because Medicaid is the budget-buster of government funded health insurance. Its budget busting propensities are most pronounced at the intersection of Medicaid and the government-funded health insurance program we do love to discuss: Medicare.

This …

The Power To Block The Affordable Care Act: What Are The Limits?, John D. Kraemer, Lawrence O. Gostin

Georgetown Law Faculty Publications and Other Works

Though Supreme Court upheld most parts of the Affordable Care Act (ACA), Congress’ goals in enacting it could still be frustrated by non-implementation. During his campaign for president, Governor Romney promised “to issue Obamacare waivers to all fifty states.” While such blanket waivers would likely violate the Constitution’s Take Care Clause, the ACA does permit other waivers. To be lawful, however, they must meet certain requirements designed to enhance access and lower cost. A president who opposes the ACA might be able to limit its implementation by refusing to issue premium subsidies in federally operated insurance exchanges, and this might …

Access To Medicaid: Recognizing Rights To Ensure Access To Care And Services, Colleen Nicholson

University of Michigan Journal of Law Reform Caveat

The Supreme Court has defined Medicaid as “a cooperative federal-state program through which the Federal Government provides financial assistance to States so that they may furnish medical care to needy individuals.” In June 2012, the Court found the Patient Protection and Affordable Care Act’s (PPACA) Medicaid expansion unconstitutional. The Court took issue with the threat to withhold all of a state’s Medicaid funding if they did not comply with the expansion, finding it coercive and a fundamental shift in the Medicaid paradigm. However, Medicaid in its current form may not always be effective at providing beneficiaries with timely access to …

Affordable Care Act Litigation: The Supreme Court And The Future Of Health Care Reform, Lawrence O. Gostin, Kelli K. Garcia

Georgetown Law Faculty Publications and Other Works

In Florida v. HHS, a lawsuit brought on behalf of 26 states challenging the constitutionality of the Patient Protection and Affordable Care Act (ACA), the Supreme Court will determine the future direction of health care reform in the United States. During the unprecedented 5-1/2 hours of oral arguments, the Court will hear 4 issues: the individual purchase mandate, severability, the Medicaid expansion and the Anti-Injunction Act.

The states challenging the ACA maintain that the purchase mandate uniquely penalizes individuals for failing to purchase insurance. Uninsured individuals, however, rarely do nothing. Instead, they self-insure, rely on family, and cost-shift to …

Why It's Called The Affordable Care Act, Nicholas Bagley, Jill R. Horwitz

Articles

The Patient Protection and Affordable Care Act of 2010 (“ACA”) raises numerous policy and legal issues, but none have attracted as much attention from lawyers as Section 1501. This provision, titled “Maintenance of Mini-mum Essential Coverage,” but better known as the “individual mandate,” requires most Americans to obtain health insurance for themselves and their dependents by 2014. We are dismayed that the narrow issue of the mandate and the narrower issue of free riding have garnered so much attention when our nation’s health-care system suffers from countless problems. By improving quality, controlling costs, and extending coverage to the uninsured, the …

Free Rider: A Justification For Mandatory Medical Insurance Under Health Care Reform?, Douglas A. Kahn, Jeffrey H. Kahn

Articles

Section 1501 of the Patient Protection and Affordable Care Act added section 5000A to the Internal Revenue Code to require most individuals in the United States, beginning in the year 2014, to purchase an established minimum level of medical insurance. This requirement, which is enforced by a penalty imposed on those who fail to comply, is sometimes referred to as the “individual mandate.” The individual mandate is one element of a vast change to the provision of medical care that Congress implemented in 2010. The individual mandate has proved to be controversial and has been the subject of a number …

The Unaffordable Health Care Act - A Reponse To Professors Bagley And Horwitz, Douglas A. Kahn, Jeffrey H. Kahn

Articles

The Patient Protection and Affordable Care Act of 2010 has stirred considerable controversy. In the public debate over the program, many of its proponents have defended it by focusing on what is sometimes called the “free-rider” problem. In a prior article, we contended that the free-rider problem has been greatly exaggerated and was not a significant factor in the congressional decision to adopt the Act. We maintained that the free-rider issue is a red herring advanced to trigger an emotional attraction to the Act and distract attention from the actual issues that favor and disfavor its adoption. In a recently …

Entitlements: Not Just A Health Care Problem, Andrew G. Biggs

The University of New Hampshire Law Review

[Excerpt] “A new consensus on entitlement reform has developed in Washington: rising per-capita health care spending is the only real crisis besetting the government‘s entitlement programs, while America‘s aging population and Social Security play minor roles at best. Some cite this view to shift the policy emphasis from entitlement cost control to the restructuring of the U.S. health sector, including private health care. But this new consensus is flawed. Using standard accounting practices and including all major government entitlement programs, population aging will play an equal role with health care cost growth over the next seventy-five years and a significantly …

Public-Private Partnerships And Insurance Regulation, Alexander A. Boni-Saenz

All Faculty Scholarship

A public-private partnership (PPP) is an institutional arrangement that embodies a collaborative approach to policy and regulation; it is a joint venture between the government and one or more private sector entities. Joint financing partnerships link public financing and private insurance to pay for certain social goods. Where the financing for social goods is fragmented and overlapping, as it is for health and social care, joint financing PPPs may help organize existing financing streams. This piece argues that partnerships of this type also present an opportunity for consumer-protective regulation of the insurance industry if certain conditions are met. Private insurers …

Making The Health Insurance Flexibility And Accountability (Hifa) Waiver Work Through Collaborative Governance, Barbara Zabawa

Faculty Works

This article examines the Health Insurance Flexibility and Accountability (HIFA) waiver introduced in 2001, focusing on its potential as a tool for collaborative governance in expanding health insurance coverage. The HIFA waiver grants states greater programmatic flexibility and encourages public-private partnerships, aiming to address the complex challenges of uninsured populations. Although the waiver has been criticized for possibly reducing benefits and increasing cost-sharing, the paper argues for its use as a vehicle to foster stakeholder collaboration. It highlights the importance of integrating diverse perspectives to design politically and economically viable health reforms. Challenges such as stakeholder engagement, accountability, and resource …

Health Care Law, Peter M. Mellette, Emily W. G. Towey, J. Vaden Hunt

University of Richmond Law Review

No abstract provided.

Breaking Through The Erisa Blockade: The Ability Of States To Access Employer Health Plan Information In Medicaid Expansion Initiatives, Barbara Zabawa

Faculty Works

The article discusses the challenges and potential solutions for states to access employer health plan information under the constraints of the Employment Retirement Income Security Act (ERISA) of 1974. It focuses on the importance of such access in supporting Medicaid expansion programs, using Wisconsin’s BadgerCare initiative as a case study. The article highlights the growing concern about "crowd out," where public health programs may displace employer-sponsored insurance, and argues for balanced public-private health coverage. It examines legal avenues for circumventing ERISA preemption, including federal law exceptions, Qualified Medical Child Support Orders (QMCSOs), and provisions under Title XIX of Medicaid. By …

The "Access" Problem: How Employee And Employer Issues May Increase Badgercare Participation By Impeding The Verification Process, Barbara Zabawa

Faculty Works

In its effort to be a welfare reform pioneer, Wisconsin has led the nation in adopting one of the most expansive public health insurance programs, "BadgerCare," to address the health care needs of working families in the post-welfare reform era. One year after BadgerCare implementation, Wisconsin is experiencing the fiscal impact of the program due to unexpectedly high enrollment in BadgerCare. While some Wisconsin leaders praise this growth rate for reducing the number of uninsured, others raise a concern that the enrollment figures may be rising due to employees opting for BadgerCare rather than employer-sponsored insurance. Consequently, this "crowd-out" effect …

Due Process, Supreme Court New York County: Ramanadhan V. Wing

Touro Law Review

No abstract provided.