Section 1332 of the ACA allows states to be innovative in their approach to healthcare reform by obtaining 1332 waivers from the federal government. States can propose unique, state-specific solutions – which can include fairly substantial changes in terms of how the Affordable Care Act is implemented in the state – as long as consumer protections are maintained, people don’t lose coverage, and the federal government doesn’t have to spend any more than they would have without the state’s innovation.
In order to be approved, a state’s 1332 waiver proposal must ensure that:
- Residents will have access to coverage that is at least as comprehensive as it would be without the waiver.
- Premiums and cost-sharing have to be at least as affordable as they would be without the waiver.
- At least as many people have to be covered under the state’s new approach as would be covered without the waiver.
- The state’s approach cannot result in increased federal spending.
To apply for a 1332 waiver, a state has to submit their proposal to CMS, with detailed explanations of what ACA provisions they wish to waive, how the state-specific program will be implemented, the proposed budget, and how the program will meet the four basic guidelines described above.
In 2018, the Trump administration issued new regulations pertaining to 1332 waivers, with a more lenient approach to the guardrails that the ACA created. The administration also published an overview of waiver concepts that states could potentially utilize.
Approved 1332 waivers
CMS has a web page where you can see details about the states that have submitted 1332 waivers, and the status of those proposals. As of November 2019, waivers have been approved for 13 states:
- Hawaii (eliminate SHOP exchange, effective in 2017)
- Alaska (reinsurance, effective in 2017)
- Minnesota (reinsurance, effective in 2018)
- Oregon (reinsurance, effective in 2018)
- Wisconsin (reinsurance, effective in 2019)
- Maine (reinsurance, effective in 2018)
- Maryland (reinsurance, effective in 2019)
- New Jersey (reinsurance, effective in 2019)
- North Dakota (reinsurance, effective in 2020)
- Montana (reinsurance, effective in 2020)
- Delaware (reinsurance, effective in 2020)
- Colorado (reinsurance, effective in 2020)
- Rhode Island (reinsurance, effective in 2020)
Most of the 1332 waivers that states have submitted thus far have been to implement reinsurance programs to stabilize states’ individual markets. Reinsurance reduces premiums, which means premium subsidies are smaller. The states that have created reinsurance programs have used the 1332 waivers in order to recapture the money that the federal government would otherwise have saved as a result of smaller premium subsidies. The states then get to use this “pass-through” funding to cover most of the cost of the reinsurance program. Without a 1332 waiver, the federal government would simply keep the savings.
But Georgia plans to submit a 1332 waiver that would eliminate the use of HealthCare.gov without creating a state-run exchange. And Colorado plans to use a 1332 waiver to recapture premium subsidy savings that will be generated by a new state option health plan, and use the money to improve benefits and/or coverage affordability for Colorado residents.
Vermont had planned to use a 1332 waiver to create a single-payer system. California had hoped to use a waiver to allow undocumented immigrants to buy health plans in the state’s exchange, but withdrew the waiver proposal over concerns that the Trump administration might use data from the exchange for immigration enforcement. Iowa had also submitted a complex 1332 waiver that would have overhauled the state’s insurance market, but later withdrew it when the approval process was taking longer than anticipated.
So although federal pass-through funding for reinsurance has been by far the most common use of 1332 waivers thus-far, states may soon start to introduce new concepts in their waiver proposals, and shape their markets in innovative and state-specific ways.