Risk Adjustment Payments Halted by the Trump Administration

Posted by Joe Cayetano on Jul 10, 2018 6:49:52 PM

The Trump administration stated on July 7, 2018 that it will be temporarily halting payments that help insurers meet the Affordable Care Act requirement to ensure coverage regardless of whether a person is healthy or sick. The estimated $10.4 billion being withheld cites a New Mexico US district court decision that found the formula used by the US government to calculate the payments as "arbitrary and capricious".

The New Mexico district court decision spurned the Trump administration into withholding payments, still, a Massachusetts district court upheld the formula used to calculate the payments. The withheld $10.4 billion is meant for a risk adjustment program that transfers funds from insurers who enroll healthy members to those that take on sicker members. This is meant to protect insurance companies who take on burdening cases or people with pre-existing conditions. It also removes the incentive for insurance companies to solely select healthy members.

This risk adjustment program was a provision of the Affordable Care Act, which President Trump has been constantly attempting to cut. The Centers for Medicare & Medicaid Services will be executing the hold and has asked the New Mexico circuit court to reconsider its decision and to seek a quick resolution to the legal issue.

Insurers and opponents of the President find that the court's decision and his actions are damaging, even if the withholding of payments is temporary. They fear that this is a "new market disruption" that would create more uncertainty and would greatly drive the current costs of medical premiums higher. Whether or not the halt is temporary is unknown as there is no definite timeline for the suspension nor is there a definite trigger for resuming of payments in the program.

Where does this leave high-risk patients or patients in immediate need of a procedure or funding for one? Tapping into one's savings is an option if savings are available. One could pay out of pocket if funds are available. Another option is crowdfunding but that comes with the risk of not reaching your goals or not getting any funds at all. Last, technology like ours, eusoh, provides patients with the option of crowdfunding or crowdsourcing, where users can manage and share expenses together. Platforms, like eusoh, are being built to provide users an option that does not involve pricey monthly premiums.

What does the future hold for the Trump administration's decision? Will it destabilize "Obamacare"? Will the New Mexico district court have their decision overturned? The insurers are urging the government and looking for a legal and regulatory path to reinstate the funding. But what can the insurers do? What last-minute options do they have aside from boosting premiums? Who knows which way the Trump administration, the district courts and the insurers go. Whichever way they go, there are millions of Americans needing a decision or a new option.


Topics: aca, trump, risk adjustment, health insurance, Healthcare

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