Report text available as:

  • TXT
  • PDF   (PDF provides a complete and accurate display of this text.) Tip ?
                                                      Calendar No. 190
116th Congress }                                              { Report
                                SENATE
 1st Session   }                                              { 116-86
               
_______________________________________________________________________

 
                     REPEAL INSURANCE PLANS OF THE

                        MULTI-STATE PROGRAM ACT

                               __________

                              R E P O R T

                                 OF THE

                   COMMITTEE ON HOMELAND SECURITY AND

                          GOVERNMENTAL AFFAIRS

                          UNITED STATES SENATE

                              TO ACCOMPANY

                                S. 1378

                 TO REPEAL THE MULTI-STATE PLAN PROGRAM

                
                [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]


               September 10, 2019.--Ordered to be printed
               
               
                                 ________
                       
                   U.S. GOVERNMENT PUBLISHING OFFICE
                
89-010                       WASHINGTON: 2019
_____________________________________________________________________________               
               
               
               
        COMMITTEE ON HOMELAND SECURITY AND GOVERNMENTAL AFFAIRS

                    RON JOHNSON, Wisconsin, Chairman
ROB PORTMAN, Ohio                    GARY C. PETERS, Michigan
RAND PAUL, Kentucky                  THOMAS R. CARPER, Delaware
JAMES LANKFORD, Oklahoma             MAGGIE HASSAN, New Hampshire
MITT ROMNEY, Utah                    KAMALA D. HARRIS, California
RICK SCOTT, Florida                  KYRSTEN SINEMA, Arizona
MICHAEL B. ENZI, Wyoming             JACKY ROSEN, Nevada
JOSH HAWLEY, Missouri

                Gabrielle D'Adamo Singer, Staff Director
                   Joseph C. Folio III, Chief Counsel
       Patrick J. Bailey, Chief Counsel for Governmental Affairs
              Joshua P. McLeod, Professional Staff Member
               David M. Weinberg, Minority Staff Director
               Zachary I. Schram, Minority Chief Counsel
         Yelena L. Tsilker, Minority Professional Staff Member
                     Laura W. Kilbride, Chief Clerk
                     
                     
                     

                                                       Calendar No. 190
116th Congress }                                             { Report
                                 SENATE
 1st Session   }                                             { 116-86

======================================================================

 
         REPEAL INSURANCE PLANS OF THE MULTI-STATE PROGRAM ACT

                                _______
                                

               September 10, 2019.--Ordered to be printed

                                _______
                                

 Mr. Johnson, from the Committee on Homeland Security and Governmental 
                    Affairs, submitted the following

                              R E P O R T

                         [To accompany S. 1378]

      [Including cost estimate of the Congressional Budget Office]

    The Committee on Homeland Security and Governmental 
Affairs, to which was referred the bill (S. 1378) to repeal the 
multi-State plan program, having considered the same, reports 
favorably thereon with an amendment (in the nature of a 
substitute) and recommends that the bill, as amended, do pass.

                                CONTENTS

                                                                   Page
  I. Purpose and Summary..............................................1
 II. Background and Need for the Legislation..........................2
III. Legislative History..............................................6
 IV. Section-by-Section Analysis......................................6
  V. Evaluation of Regulatory Impact..................................7
 VI. Congressional Budget Office Cost Estimate........................7
VII. Changes in Existing Law Made by the Bill, as Reported............8

                         I. Purpose and Summary

    S. 1378, the Repeal Insurance Plans of the Multi-State 
Program Act, or the RIP MSP Act, repeals the Multi-State Plan 
(MSP) Program authorized under Section 1334 of the Patient 
Protection and Affordable Care Act (ACA). Section 1334 directs 
the U.S. Office of Personnel Management (OPM) to ``contract 
with private health insurers in each State to offer high-
quality, affordable health insurance options called Multi-State 
Plans.''\1\ The MSP Program is not meeting statutory 
requirements under the ACA and eliminating this program will 
allow OPM to focus on mission-critical programs.\2\
---------------------------------------------------------------------------
    \1\Patient Protection and Affordable Care Act Sec. 1334 (codified 
in 42 U.S.C. Sec. 18054).
    \2\On June 18, 2018, the Committee approved S. 2221, the Repeal 
Insurance Plans of the Multi-State Program Act. That bill is 
substantially similar to S. 1378. Accordingly, this committee report is 
in large part a reproduction of Chairman Johnson's committee report for 
S. 2221, S. Rep. No. 115-277 (2018).
---------------------------------------------------------------------------

              II. Background and the Need for Legislation

    On March 23, 2010, President Barack Obama signed the ACA 
into law.\3\ Section 1334 of the ACA mandated a MSP Program to 
increase competition and provide greater insurance choices for 
consumers.\4\ To accomplish this task, the MSP authorized the 
Director of OPM to contract with health care plans to offer at 
least two multi-state plans on each state exchange for 
individual or group coverage by 2017, thereby competing against 
private plans offered through state exchanges.\5\
---------------------------------------------------------------------------
    \3\Patient Protection and Affordable Care Act, Pub. L. No. 111-148, 
124 Stat. 119 (2010); see also H.R. 3590--Patient Protection and 
Affordable Care Act, Congress.gov, https://www.congress.gov/bill/111th-
congress/house-bill/3590/all-actions (last updated Mar. 23, 2010).
    \4\U.S. Off. of Pers. Mgmt., a new Day for Federal Service: An 
Overview of the Multi-State Plan Program (2014), https://
marketplace.cms.gov/technical-assistance-resources/multistate-plan-
program.pdf; see also Robert Moffit, Will This Little-Known Obamacare 
Provision Lead to a Public Option?, Daily Signal (Jan. 15, 2015), 
http://dailysignal.com/2015/01/15/will-little-known-obamacare-
provision-lead-public-option.
    \5\Patient Protection and Affordable Care Act Sec. 1334, supra note 
1.
---------------------------------------------------------------------------
    Section 1334 was inserted into the ACA by former Senate 
Majority Leader Harry Reid during floor consideration, after 
the legislation passed the Senate Finance Committee, as part of 
a Manager's Amendment.\6\ Due to its late addition, Congress 
held no hearings to evaluate the merits of creating the MSP 
program.\7\ Staff to former Senator Edward (``Ted'') Kennedy 
explained the rushed origins of the program, stating, ``It's 
happened so fast, in a brief window, that there was not a lot 
of time for robust conversation . . . . The conversation was 
like, `this is a good idea, let's cook something up.' It was 
definitely not a thoughtful, nuanced conversation.''\8\
---------------------------------------------------------------------------
    \6\Moffit, supra note 4; S. Amdt. 3276 to H.R. 3590 (Dec. 19, 
2009).
    \7\See Robert Moffit, Dan Blair & Linda Springer, The Office of 
Personnel Management: A Power Player in America's Health Insurance 
Markets?, Heritage Found. (Feb. 19, 2010), https://www.heritage.org/
health-care-reform/report/the-office-personnel-management-power-player-
americas-health-insurance.
    \8\Sarah Kliff, No, The Public Option is Not Back From the Dead, 
Wash. Post: Wonkblog (Oct. 30, 2012), https://www.washingtonpost.com/
news/wonk/wp/2012/10/30/no-the-public-option-has-not-returned-from-the-
dead/?utm_term=.f7fddd750b03.
---------------------------------------------------------------------------
    News that some members of Congress were nearing an 
agreement to create the MSP Program became public in December 
2009 when Majority Leader Reid announced that a health reform 
working group of ten senators had arrived at a ``tentative 
consensus `that includes a public option.'''\9\ The working 
group Majority Leader Reid referenced explored several reform 
options before settling on the MSP Program. One proposal under 
discussion by the working group was a public option; however a 
public option in which the government acted directly as the 
issuer did not have enough support to pass through 
Congress.\10\ As a result, Senator Chuck Schumer (D-N.Y.) 
worked with nine of his colleagues to come up with a backup 
plan to the public option.\11\ One alternative under 
consideration by the working group was the MSP Program through 
which OPM would work with private insurers to offer health 
insurance plans to compete with other plans available on state 
exchanges.\12\ Another alternative was allowing individuals 
over the age of 55 to enroll in Medicare.\13\ It was reported 
that key Senators withheld support for the second idea, leaving 
the MSP Program all that remained.\14\ With a public option in 
which the government played the role of insurer off the table, 
the MSP Program was added to the ACA as the public option 
backup plan, described by some as ``sort of a catch-all for a 
lot of different ideas.''\15\
---------------------------------------------------------------------------
    \9\Timothy Noah, Medicare Buy-in, RIP, Slate: Public Option Wiki 
(Dec. 14, 2009), http://www.slate.com/articles/news_and_politics/
prescriptions/2009/12/public_option_wiki.html.
    \10\Kliff, supra note 8.
    \11\Id.
    \12\Id.; Senators seek to put OPM in charge of health care public 
option, Government Executive (Dec. 5, 2009) www.govexec.com/federal-
news/2009/12/senators-seek-to-put-opm-in-charge-of-healthcare-public-
option/30472/; see also, OPM could get role running national health 
plan, Government Executive (Dec. 6, 2009), www.govexec.com/pay-
benefits/2009/12/opm-could-get-role-running-national-health-plan/
30473/.
    \13\Id.
    \14\Id.
    \15\Rachana Pradhan & Paul Demko, Another Piece of Obamacare Falls 
Short, Politico (Sept. 7, 2016), http://www.politico.com/story/2016/09/
obamacare-falls-short-227854.
---------------------------------------------------------------------------
    Additionally, the law requires OPM to contract with at 
least one non-profit provider, and to ensure that at least one 
MSP option does not provide abortion coverage.\16\
---------------------------------------------------------------------------
    \16\Patient Protection and Affordable Care Act Sec. 1334, supra 
note 1.
---------------------------------------------------------------------------

The MSP program is failing to increase competition and choice

    In its sixth year since the program's implementation in 
2014, the program is both failing to fulfill program intent and 
to meet statutory requirements. The MSP Program was created to 
increase both competition and choice in state health care 
exchanges.\17\ However, only one issuer association--the Blue 
Cross Blue Shield Association (BCBSA)--has ever participated in 
the MSP Program, despite a statutory requirement for OPM to 
contract with at least two MSP issuers in all 50 states and the 
District of Columbia by 2017.\18\ Further, BCBSA already had a 
significant market share in the states that participated in the 
MSP Program,\19\ and has approximately 70 percent of the market 
share in the one remaining state participating (Arkansas) in 
the MSP Program.\20\
---------------------------------------------------------------------------
    \17\S. Rep. No. 111-89 (2009); see also Sabrina Corlette, The 
Multi-State Plans Unveiled, Geo. U. Ctr. On Health Ins. Reforms Blog 
(Sept. 30, 2013), http://chirblog.org/multi-state-plans-unveiled/.
    \18\Patient Protection and Affordable Care Act Sec. 1334, supra 
note 1; see also U.S. Off. of Pers. Mgmt., supra note 4; U.S. Off. of 
Pers. Mgmt., Multi-State Plan Program and the Health Insurance 
Marketplace: FAQs, https://www.opm.gov/healthcare-insurance/multi-
state-plan-program/consumer/?page=1#url=FAQs (last visited Apr. 4, 
2018).
    \19\Corlette, supra note 17.
    \20\Christine Monahan, Oh Where, Oh Where Are The Multi-State 
Plans?, Geo. U. Ctr. On Health Ins. Reforms Blog (June 6, 2013), http:/
/chirblog.org/oh-where-oh-where-are-the-multi-state-plans/; see also 
Sarah Goodell, The Multi-State Plan Program (Updated), Health Affairs 
(May 29, 2014), https://www.healthaffairs.org/do/10.1377/
hpb20140529.10243/full/.
---------------------------------------------------------------------------
    The Obama administration told issuers to ``assume that each 
national plan would have 750,000 people enrolled in the first 
year.''\21\ However, approximately 350,000 individuals enrolled 
in a MSP option in 2014.\22\ For plan year 2015, MSP coverage 
expanded to 36 states and 437,000 individuals.\23\ For plan 
year 2016, MSP coverage dipped to approximately 375,000 
individuals in 33 states, and in 2017 the MSP enrollment fell 
to 290,000 individuals in 22 states.\24\ By 2018, only one 
state--Arkansas--was participating in the MSP Program, and 
fewer than 48,000 individuals in Arkansas are likely to enroll 
in MSP plans in 2019.\25\ With only one state participating, 
the program has a state participation success rate of 1.9 
percent.
---------------------------------------------------------------------------
    \21\Robert Pear, U.S. Set to Sponsor Health Insurance, N.Y. Times 
(Oct. 27, 2012), https://www.nytimes.com/2012/10/28/health/us-to-
sponsor-health-insurance-plans-nationwide.html.
    \22\Document productions from U.S. Off. of Pers. Mgmt. provided to 
S. Comm. on Homeland Sec. & Governmental Aff. (Oct. 6, 2017 and Feb. 
13, 2018) (on file with S. Comm. on Homeland Sec. & Governmental Aff.).
    \23\Id.
    \24\Id.
    \25\E-mail from U.S. Off. of Pers. Mgmt. staff to S. Comm. on 
Homeland Sec. & Governmental Aff. staff (on file with S. Comm. on 
Homeland Sec. & Governmental Aff.).
---------------------------------------------------------------------------
    Shortly prior to passage of the ACA, the Congressional 
Budget Office (CBO) questioned the utility of the MSP Program 
and whether issuers would participate.\26\ In a 2009 letter to 
Majority Leader Reid, CBO wrote:
---------------------------------------------------------------------------
    \26\Letter from Douglas W. Elmendorf, Dir., Cong. Budget Off., to 
Harry Reid, Majority Leader, U.S. Senate (Dec. 19, 2009), http://
www.cbo.gov/sites/default/files/cbofiles/ftpdocs/108xx/doc10868/12-19-
reid_letter_managers_correction_noted.pdf.

          [w]hether insurers would be interested in offering 
        [MSP] plans is unclear, and establishing a nationwide 
        plan comprising only nonprofit insurers might be 
        particularly difficult. Even if such plans were 
        arranged, the insurers offering them would probably 
        have participated in the insurance exchanges anyway, so 
        the inclusion of this provision did not have a 
        significant effect on the estimates of federal costs or 
        enrollment in the exchanges.\27\
---------------------------------------------------------------------------
    \27\Id.

    At the time, CBO also estimated that the creation of MSP 
was ``unlikely to have much effect on average insurance 
premiums because the existence of that public plan would not 
substantially change the average premiums that would be paid in 
the exchanges.''\28\ In evaluating the merits of S. 1378, CBO 
found that MSPs are not the lowest-cost or second-lowest cost 
silver plans in any rating areas where they are offered.\29\ 
Because of this, eliminating MSPs would not affect Federal 
subsidies for health insurance purchased through the 
marketplaces, nor would it affect the Federal budget.\30\
---------------------------------------------------------------------------
    \28\Id.
    \29\Cong. Budget Off., Congressional Budget Office Cost Estimate: 
S. 1378 Repeal Insurance Plans of the Multi-State Program Act (2019), 
https://www.cbo.gov/publication/55294.
    \30\Id.
---------------------------------------------------------------------------
    On April 29, 2019, OPM notified members of Congress that 
the Department would suspend MSP Program operations, beginning 
with the 2020 plan year.\31\ In letters to Committee Chairman 
Ron Johnson and Ranking Member Gary Peters, Acting Director 
Margaret Weichert noted that despite OPM's efforts to encourage 
issuer participation in the MSP Program, beginning in 2016, 
issuer interest declined considerably.\32\ Due to OPM's 
inability to achieve the statutory goals and objectives of the 
Program, OPM determined ``the prudent course of action is to 
suspend MSP Program operations.''\33\
---------------------------------------------------------------------------
    \31\Letter from Margaret Weichert to Sen. Ron Johnson (Apr. 29, 
2019).
    \32\Id.
    \33\Id.
---------------------------------------------------------------------------

Obamacare's MSP Program detracts OPM from mission-critical programs 
        that serve the Federal workforce

    OPM, the agency tasked under law with the administration of 
the MSP Program, supports passage of S. 1378, noting that 
``[r]epealing this statutory requirement would allow OPM to 
further strengthen its capacity to meet the important needs of 
our benefit programs serving the 2.7 million employees of the 
Federal workforce and over 2 million Federal workforce 
retirees.''\34\
---------------------------------------------------------------------------
    \34\Letter from OPM Director Pon to Chairman Ron Johnson and 
Ranking Member McCaskill, S. Comm. on Homeland Sec. & Governmental Aff. 
(June 15, 2018) (on file with S. Comm. on Homeland Sec. & Governmental 
Aff.).
---------------------------------------------------------------------------
    Since 1978, OPM's core mission has been to serve the 
Federal workforce.\35\ The creation of the MSP Program diverted 
OPM's focus from this mission for the first time by requiring 
OPM to begin providing non-Federal services to the American 
public.\36\ From fiscal year (FY) 2011 to FY 2019, OPM spent 
approximately $60 million in ``salaries and expenses'' to 
administer the MSP Program.\37\ This funding supported 42 full-
time equivalents in FY2017 alone.\38\
---------------------------------------------------------------------------
    \35\Our Mission, Role & History, U.S. Off. of Pers. Mgmt., https://
www.opm.gov/about-us/our-mission-role-history/ (last visited Apr. 4, 
2018).
    \36\U.S. Off. of Pers. Mgmt., Congressional Budget Justification: 
Fiscal Year 2018 2 (2017), https://www.opm.gov/about-us/budget-
performance/budgets/congressional-budget-justification-fy2018.pdf.
    \37\Document production from U.S. Off. of Pers. Mgmt. provided to 
S. Comm. on Homeland Sec. & Governmental Aff. (Oct. 6, 2017) (on file 
with S. Comm. on Homeland Sec. & Governmental Aff.).
    \38\Id.
---------------------------------------------------------------------------
    Prior to FY2019, additional resources were requested for 
the MSP Program in the annual Congressional Budget 
Justification instead of being requested for mission-critical 
programs that serve the Federal workforce and its retirees. 
Diverting OPM resources away from its core mission is 
significant given the agency is currently struggling to provide 
acceptable levels of service to Federal employees.\39\ For 
instance, in fiscal year 2017, OPM requested $3.35 million less 
money to support processing of its substantial backlog of 
Federal retirement claims.\40\ At the same time, OPM expended 
$10.3 million for MSP Program salaries and expenses alone.\41\ 
In its FY2019 Congressional Budget Justification, OPM 
recognized the lack of interest and participation in the MSP 
Program and proposed reallocating funding to the increasing 
needs of other mission critical programs.\42\
---------------------------------------------------------------------------
    \39\For example, as of June 30, 2019, OPM had an inventory of 
18,501 in unprocessed retirement claims. See Michael O' Connell, OPM 
Cuts Retirement Backlog to its Lowest Level in More Than a Year, Fed. 
News Radio (Jan. 5, 2018), https://federalnewsradio.com/retirement/
2018/01/opm-cuts-retirement-backlog-to-its-lowest-level-in-more-than-a-
year/; see also U.S. Off. of Pers. Mgmt. Statistical Abstracts: Fiscal 
Year 2016 (2017).
    \40\U.S. Off. of Pers. Mgmt., supra note 36.
    \41\Document production from U.S. Off. of Pers. Mgmt. provided to 
S. Comm. on Homeland Sec. & Governmental Aff., supra note 37.
    \42\U.S. Office of Pers. Mgmt., Congressional Budget Justification 
and Annual Performance Plan 85 (2019), https://www.opm.gov/about-us/
budget-performance/budgets/congressional-budget-justification-
fy2019.pdf.
---------------------------------------------------------------------------
    S. 1378 will allow OPM the ability to focus on mission 
critical programs that benefit members of the Federal 
workforce, tribes and tribal organizations, and retirees.
    Lastly, the volume of staffing devoted to the program has 
been disproportionate to the volume of people served. In 2018, 
42 employees served no more than 55,000 participants in 
Arkansas.\43\ The Federal Employee Health Benefits Program 
(FEHBP), by comparison, had 117 full-time employees but served 
8.2 million people.\44\ Therefore, throughout most of the 
program's existence, OPM has dedicated only 3.3 employees per 
100,000 FEHBP enrollees while dedicating 14 employees per 
100,000 MSP enrollees.
---------------------------------------------------------------------------
    \43\Goodell, supra note 20.
    \44\See Kirstin B. Blom & Ada S. Cornell, Cong. Res. Serv., R43922, 
Federal Employees Health Benefits (FEHB) Program: An Overview (2016), 
https://fas.org/sgp/crs/misc/R43922.pdf.
---------------------------------------------------------------------------
    In addition to the MSP Program detracting from OPM's 
mission-critical programs, the program continues to be a 
concern for the OPM Office of Inspector General (OIG). In 
December 2016, the OIG issued a Management Alert for the 
program due to a lack of participation on the part of states 
and providers, and confusion about the name incorrectly 
signaling coverage would cross state boundaries when MSP 
coverage does not.\45\ In FYs 2016 and 2017, the OIG also 
included the program in its list of top management challenges 
facing the agency.\46\ S. 1378 will repeal the MSP Program and 
allow OPM to focus exclusively on mission-critical programs.
---------------------------------------------------------------------------
    \45\Memorandum from Norbert E. Vint, Deputy Inspector Gen., U.S. 
Off. of Pers. Mgmt. Off. of Inspector Gen., to Beth F. Cobert, Acting 
Dir., U.S. Off. of Pers. Mgmt. (Dec. 8, 2016), https://www.opm.gov/our-
inspector-general/reports/2016/management-alert-status-of-the-multi-
state-plan-program-4a-hi-00-17-013.pdf.
    \46\U.S. Off. of Pers. Mgmt. Off. of Inspector Gen., Top Management 
Challenges: Fiscal Year 2017 (2017), https://www.opm.gov/our-inspector-
general/special-reports-and-reviews/fy2017-top-management-
challenges.pdf; see also Memorandum from Norbert E. Vint, Deputy 
Inspector Gen., U.S. Off. of Pers. Mgmt. Off. of Inspector Gen. to Beth 
F. Cobert, Acting Dir., U.S. Off. of Pers. Mgmt. (Oct. 12, 2016), 
https://www.opm.gov/our-inspector-general/special-reports-and-reviews/
fy2016-management-challenges.pdf.
---------------------------------------------------------------------------

                        III. Legislative History

    S. 1378, the RIP MSP Act, was introduced on May 8, 2019, by 
Chairman Ron Johnson along with Senators John Barrasso, Mike 
Braun, Roger Wicker, Mike Lee, Lamar Alexander, Michael Enzi, 
Kevin Cramer, and Rand Paul. The bill was referred to the 
Committee on Homeland Security and Governmental Affairs.
    The Committee considered S. 1378 at a May 15, 2019 business 
meeting. A substitute amendment offered by Chairman Johnson 
removed a rescission of unused funds provision, and a related 
Sense of Congress, to ensure Federal funds remain in OPM's 
control for authorized functions. The substitute amendment was 
adopted by unanimous consent.
    The Committee ordered S. 1378, as amended, reported 
favorably, by a roll call vote of 8 ``yeas'' to 4 ``nays.'' 
Senators voting in the affirmative were Johnson, Portman, Paul, 
Lankford, Romney, Scott, Hawley, and Sinema. Senators voting in 
the negative were Peters, Carper, Hassan, and Rosen. For the 
record only, Senator Enzi voted ``yea'' by proxy and Senator 
Harris voted ``nay'' by proxy.

        IV. Section-by-Section Analysis of the Bill, as Reported


Section 1. Short title

    This section establishes the short title of the bill as the 
``Repeal Insurance Plans of the Multi-State Program Act'' or 
the ``RIP MSP Act.''

Section 2. Repeal of Multi-State Plan Program

    This section repeals section 1334, the MSP Program, of the 
Patient Protection and Affordable Care Act (Public Law 111-
148), effective January 1, 2020. It requires the termination of 
external review by the OPM Director, and no later than 60 days 
after the date of enactment of the legislation, the OPM 
Director to brief the Committee on Homeland Security and 
Governmental Affairs and the Committee on Health, Education, 
Labor, and Pensions of the Senate and the Committee on 
Oversight and Reform and the Committee on Energy and Commerce 
of the House of Representatives. The briefing must include 
information concerning how OPM and MSP issuers are notifying 
current enrollees that there will no longer be MSP options 
available; a description of how the OPM Director will work with 
the Secretary of Health and Human Services to ensure no MSP 
plans are made available; and a timeline detailing how OPM will 
close the information technology portal that MSP issuers 
utilize.

                   V. Evaluation of Regulatory Impact

    Pursuant to the requirements of paragraph 11(b) of rule 
XXVI of the Standing Rules of the Senate, the Committee has 
considered the regulatory impact of this bill and determined 
that the bill will have no regulatory impact within the meaning 
of the rules. The Committee agrees with the Congressional 
Budget Office's statement that the bill contains no 
intergovernmental or private-sector mandates as defined in the 
Unfunded Mandates Reform Act and would impose no costs on 
state, local, or tribal governments.

             VI. Congressional Budget Office Cost Estimate

                                     U.S. Congress,
                               Congressional Budget Office,
                                      Washington, DC, May 23, 2019.
Hon. Ron Johnson,
Chairman, Committee on Homeland Security and Governmental Affairs, U.S. 
        Senate, Washington, DC.
    Dear Mr. Chairman: The Congressional Budget Office has 
prepared the enclosed cost estimate for S. 1378, the Repeal 
Insurance Plans of the Multi-State Program Act.
    If you wish further details on this estimate, we will be 
pleased to provide them. The CBO staff contact is Kevin 
McNellis.
            Sincerely,
                                                Keith Hall,
                                                          Director.
    Enclosure.

         [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    

    S. 1378 would repeal the multi-state plan program 
established by Section 1334 of the Affordable Care Act (ACA). 
Section 1334 requires the Office of Personnel Management (OPM) 
to contract with health insurers to offer multi-state plan 
(MSP) insurance options on each exchange in each state. Under 
current law, the plans generally must meet the various 
insurance requirements under the ACA and are available to 
eligible individuals and small business. The repeal would be 
effective January 1, 2020. Within 60 days of enactment, the 
bill also would require OPM to brief the Senate Committee on 
Homeland Security and Governmental Affairs; the Senate 
Committee on Health, Education, Labor, and Pensions; the House 
Committee on Oversight and Reform; and the House Committee on 
Energy and Commerce on OPM's efforts to wind-down the program.
    OPM reports that in 2019 Arkansas Blue Cross and Blue 
Shield is the only insurer to offer MSPs, and such plans are 
only available in Arkansas. Premium data from the Department of 
Health and Human Services (HHS) show that MSPs are not the 
lowest cost or second-lowest cost silver plans in any rating 
areas where they are offered. Because premiums for silver plans 
with the second-lowest-cost are the basis for calculating 
federal subsidies for health insurance purchased through the 
marketplaces, eliminating plans with premiums higher than those 
second-lowest cost plans would not affect subsidies and thus 
the bill's enactment would not affect the federal budget.
    The CBO contact for this estimate is Kevin McNellis. The 
estimate was approved by Leo Lex, Deputy Assistant Director for 
Budget Analysis.

       VII. Changes in Existing Law Made by the Bill, as Reported

    In compliance with paragraph 12 of rule XXVI of the 
Standing Rules of the Senate, changes in existing law made by 
S. 1378 as reported are shown as follows (existing law proposed 
to be omitted is enclosed in brackets, new matter is printed in 
italic, and existing law in which no change is proposed is 
shown in roman):

PATIENT PROTECTION AND AFFORDABLE CARE ACT

           *       *       *       *       *       *       *


TITLE I--QUALITY, AFFORDABLE HEALTH CARE FOR ALL AMERICANS

           *       *       *       *       *       *       *


Subtitle D--Available Coverage Choices for All Americans

           *       *       *       *       *       *       *


PART 1--ESTABLISHMENT OF QUALIFIED HEALTH PLANS

           *       *       *       *       *       *       *



SEC. 1301. QUALIFIED HEALTH PLAN DEFINED

    (a) * * *
          (1) * * *
          (2) Inclusion of co-op plans [and multi-state 
        qualified health plans].--Any reference in this title 
        to a qualified health plan shall be deemed to include a 
        qualified health plan offered through the CO-OP program 
        under section 1322, [and a multi-State plan under 
        section 1334,] unless specifically provided for 
        otherwise.
          (3) * * *
          (4) Variation based on rating area.--A qualified 
        health plan[, including a multi-State qualified health 
        plan,] may as appropriate vary premiums by rating area 
        (as defined in section 2701(a)(2) of the Public Health 
        Service Act.)

           *       *       *       *       *       *       *


PART III--STATE FLEXIBILITY RELATING TO EXCHANGES

           *       *       *       *       *       *       *



SEC. 1324. LEVEL PLAYING FIELD

    (a) In General.--Notwithstanding any other provision of 
law, any health insurance coverage offered by a private health 
insurance issuer shall not be subject to any Federal or State 
law described in subsection (b) if a qualified health plan 
offered under the Consumer Operated and Oriented Plan program 
under section 1322 [, or a multi-State qualified health plan 
under section 1334,] is not subject to such law.

           *       *       *       *       *       *       *