Maryland's year of health care

The General Assembly session that ends at midnight on Monday has seen its share of controversial issues, from gun control to medical marijuana, and of memorable moments, perhaps the most notable of which was when Republican Del. Meagan Simonaire gave a floor speech endorsing a ban on so-called “conversion therapy” for gay youth, which she said her father, Republican state Sen. Bryan Simonaire, suggested she try after she came out as bisexual. The session has had some election-year political jockeying, too, as Gov. Larry Hogan sparred with Democrats over changes to the state school construction program.

But the most significant thing that’s likely to emerge from the 90 days of lawmaking came with little fanfare or controversy — one of the most aggressive efforts in the country to protect the state’s Affordable Care Act insurance exchange from collapsing under a series of blows from the Republican Congress and President Donald Trump. Maryland figured out a way to start and fund a reinsurance pool — a tax on all health insurers (not just those that operate on the exchange) that replaces a federal levy Congress temporarily abolished. Some Republicans opposed it, but Democrats overwhelmingly supported it, as did Governor Hogan and the state’s largest insurer, CareFirst BlueCross BlueShield.

The way it will work is by raising funds to cover costs from the most expensive patients on the exchange and thus make the remaining risk pool less risky — and lower premiums for everyone else. The principle behind the plan isn’t original; Obamacare included a national reinsurance program, and a handful of states have set them up, though all of them with the help of the federal government. Maryland is a pioneer in figuring out a way to do it at the same time that the Trump administration and Congress are actively trying to kill Obamacare. It is expected to significantly moderate increases to insurance rates on the exchange, which were otherwise expected to spike by 50 percent or more next year.

But it doesn’t entirely solve the problem. First of all, the tax deal only lasts one year (to match the federal hiatus, which is also only good for 2019). Other legislation requires the state to apply for federal help to support the reinsurance pool on a long-term basis, and at one point the Trump administration actually encouraged states to do that. But since then, the signals have been decidedly mixed, and Maryland may wind up being on its own. And second, the pressure on the risk pool in Maryland and elsewhere will only intensify when the requirement that individuals buy health insurance expires in 2019 as a result of the Trump/GOP tax law. Fewer young, healthy customers will buy insurance, making the risk pool older, sicker and more expensive.

The legislation includes a provision calling on a commission to study other potential reforms, including establishing a state-level mandate (like Massachusetts has), but it sets a deadline of Dec. 31, 2019 for the group to report its findings. That’s too late. The legislature needs to be in a position to potentially act on that idea immediately in the 2019 General Assembly session, and it already has an intriguing model in hand in the form of legislation considered but not enacted this year that would allow consumers to use the penalty they paid for failing to purchase health insurance as a down payment on a policy. (Because of federal subsidies, many wouldn’t have to pay anything more than the penalty in the first place.)

There is one remaining piece of health care legislation this year that lawmakers should work to pass before they adjourn. Health care advocates sought to follow up on last year’s anti-price gouging bill for generic prescription drugs with one that would regulate prices for name-brand drugs. The idea was unprecedented nationally and would be complicated to carry out, and so a House committee converted the legislation into a bill requiring a study of the idea. It passed the House 137-0 on Friday, but it will take some effort to move it through the Senate in the time remaining. Given the outsized role drugs play in health care costs, we urge the Senate to make it a priority.

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