Colorado Plan Shows the Coercion Behind the Public “Option”

Former Vice President Joe Biden’s political comeback prompted health care stocks to surge last month following the Super Tuesday primaries. The rally, which occurred before the coronavirus pandemic took hold in the United States, stemmed in large part from Wall Street’s belief that Biden represents less of a threat to the sector as a potential president than Vermont Sen. Bernie Sanders’ single-payer health-care system.

But anyone who considers Biden’s alternative to single payer, the so-called “public option,” innocuous should look to Colorado. Lawmakers in the Centennial State recently revealed their version of the concept, and it represents an “option” in name only. Indeed, the state’s plan contemplates a level of coercion that in some respects exceeds that of Sanders’ system of socialized medicine.

Big Government Forces Hospitals’ Participation

For starters, the legislative proposal dictates prices for hospitals, based on a percentage of Medicare rates. As one might expect, the bill’s supporters believe the rates proposed in the legislation represent fair reimbursement levels, while some hospital executives disagree.

But the bill would also take away hospitals’ negotiating leverage, by requiring all Colorado facilities to participate in the new insurance offering. Hospitals refusing to participate would face fines of up to $40,000 per day. And if the prospect of nearly $1.5 million in government-imposed sanctions does not force a recalcitrant facility into submission, the bill also permits Colorado’s insurance commissioner to “suspend, revoke, or impose conditions on the hospital’s license.”

Think about that for a moment: The government forces hospitals to offer patients a service—even if the government’s price for that service could lead them to incur financial losses—and threatens to take away their license to do business if they refuse. That level of heavy-handed government involvement far exceeds the individual mandate in Obamacare.

Insurers Required to Participate, Too

The bill similarly requires all Colorado insurers to offer the new government-dictated “option” in each county in which they offer Obamacare exchange products. In counties where only one insurer currently offers coverage, the bill directs the insurance commissioner to “require carriers to offer the Colorado option in specific counties,” such that at least two carriers offer the plan in every county.

According to one report, the bill’s sponsors called their new offering the “Colorado option” rather than the “public option” because lawmakers did “not want to put the state budget at risk by creating a government-run insurance company.” Instead, lawmakers want to dragoon insurers into assuming that risk, even as the bill prohibits efforts by insurers to absorb potential losses from the “Colorado option” by raising rates elsewhere.

Worse Than Berniecare?

Sanders’ legislation would effectively put private insurers out of business, by making coverage for services covered by the single-payer system “unlawful.” The issue of whether to ban private insurance, and take away individuals’ ability to keep their current coverage, became a defining characteristic of Democrats’ nominating contest.

But the Colorado legislation could put private insurers and hospitals out of business, if they refuse the state’s commands. At least Sanders’ proposal allows hospitals to opt out of the government system if they decide—few would, but they do have that choice.

The Colorado legislation shows how Obamacare set a dangerous precedent, which Democrats want to extend throughout the health-care system. Just as Obamacare forced all Americans to buy a product for the first time ever, now lawmakers want to force hospitals and insurers to treat patients, even at their financial peril. Each could face a Hobson’s choice: Putting themselves out of business by incurring losses on “Colorado option” patients, or taking the “option” to decline to participate, at which point the state will regulate them out of business.

Colorado’s proposal of dubious merit and equally dubious constitutionality demonstrates the way in which even purported moderates like Biden have embraced a health-care agenda defined by ever-increasing levels of government intrusion and coercion. At present, Sanders’ single-payer legislation represents the far end of that continuum, but liberals will use proposals like Colorado’s “public option” to get there.

This post was originally published at The Federalist.

The Left’s Health Care Vision a Prescription for Brute Government Force

Even as Democrats inveigh against President Trump for his alleged norm-shattering and contempt for the rule of law, their health care plans show a growing embrace of authoritarianism. For instance, Rep. Adam Schiff (D-CA) recently dubbed the President’s July 25 call with Ukrainian President Volodymyr Zelensky “a classic mafia-like shakedown.” He knows of which he speaks, because the Democratic agenda on health care now includes threats to destroy any entities failing to comply with government-dictated price controls.

The latest evidence comes from Colorado, where several government agencies recently submitted a draft report regarding the creation of a “state option” for health insurance. The plan would not create a state-run health insurer; instead, it would see agencies dragooning private sector firms to comply with government diktats.

The plan would “require insurance carriers that offer plans in a major market,” whether individual, small group, or large group, “to offer the state option as well.” In these state-mandated plans insurers must offer, carriers would have to abide by stricter controls on their administrative costs, in the form of medical loss ratio requirements, than those dictated by Obamacare.

For medical providers, the Colorado plan would use “payment benchmarks” to cap reimbursement amounts for doctors and hospitals. And if hospitals decline to accept these government-imposed price controls, the report ominously says that “the state may implement measures to ensure health systems participate.”

In comments to reporters, Colorado officials made clear their intent to coerce providers into this price-controlled system. Insurance Commissioner Michael Conway admitted that “If our hospital systems don’t participate, this won’t work….We can’t allow that to happen.” The head of Colorado’s Department of Health Care Policy and Financing, Kim Bimestefer, said that “if we feel that the hospitals are not going to participate, we will require their participation.”

State officials did not elaborate on the mechanisms they would use to compel participation in the state option. But they could attempt to require hospitals and insurers to participate in the new plan to maintain their license to operate in Colorado—a likely unconstitutional condition of licensure.

In threatening this level of coercion—agree to price controls, or we’ll shut down your business—Colorado Gov. Jared Polis imitated his fellow Democrat, House Speaker Nancy Pelosi. Pelosi’s proposed drug pricing bill, up for a vote in the House as soon as next month, would impose excise taxes of up to 95 percent of a drug’s sale price if companies refuse to “negotiate” with the federal government.

In its analysis of Pelosi’s legislation, the Congressional Budget Office (CBO) noted that, because drug makers could not deduct the 95 percent excise tax for income tax purposes, “the combination of income taxes and excise taxes on the sales could cause the drug manufacturer to lose money if the drug was sold in the United States.” Perhaps unsurprisingly, CBO concluded that the excise tax would not generate “any significant increase in revenues,” as “manufacturers would either participate in the negotiating process”—because they have no effective alternative—“or pull a particular drug out of the U.S. market entirely.”

CBO also noted, in a classic bit of understatement, that Pelosi’s bill “could result in litigation,” for threatening losses on any company that dares defy the government’s offer of “negotiation.” But the left seems uninterested in abiding by limits on government power—or the consistency of its own arguments. As I noted this spring, other proposed legislation in Congress would abolish the private health care market. Less than one decade after forcing all Americans to buy a product for the first time ever, in the form of Obamacare’s insurance mandate, liberals now want to prohibit all Americans from purchasing care directly from their doctors.

These recent proposals continue a virulent strain of authoritarianism that has permeated progressivism’s entire history. Franklin Roosevelt threatened to invoke emergency powers during his first inaugural address, and Rahm Emanuel infamously said during the Great Recession that “you never want a serious crisis to go to waste.” Make no mistake: The health care system needs patient-centered reform. But the true crisis comes from the progressives who would utilize blunt government force to seize control of one-fifth of the nation’s economy.

This post was originally published at The Daily Wire.

Is Obamacare Working? Broken Promises and a Broken System

Developments this week suggest that for many Americans, Obamacare will not be worthwhile. The administration’s report on premiums claimed that insurance rates will be “lower than projected” — clever code for “premiums will go up by slightly less” than the 2009 Congressional Budget Office estimates. That’s far from the $2,500 premium reduction that Obama promised his health plan would deliver, during his 2008 campaign.

What’s more, many of those exchange plans will have limited physician networks, as reported by The Times this week. The problem is obvious: “Decades of experience with Medicaid, the program for low-income people, show that having an insurance card does not guarantee access to specialists or other providers.”

While Obamacare may not be worthwhile for many Americans, implementing it certainly has been a problem — for both state exchanges and the federal government. Wednesday morning, The Wall Street Journal reported that Colorado, like Oregon before it, would delay online purchases of health insurance through its exchange; “some people will have to enroll by phone or in person” instead. Later Wednesday, the District of Columbia announced delays for its exchange; customers in the nation’s capital won’t be able to see what insurance subsidies (if any) they qualify for until at least November.

Then on Thursday — even as President Obama was publicly claiming that Obamacare is “here to stay” — The Associated Press reported another series of delays, these postponing online sign-ups for both the federally run small business exchanges and the Spanish-language exchange.

The combination of broken premium promises, limited access to care and continued implementation failures all send one clear message: Congress should stop Obamacare before it starts, and focus on common-sense solutions that can reduce health care costs for all Americans.

This post was originally published at The New York Times.

Obamacare Exchange Delays and Glitches Keep Coming

With just six days before the Obamacare insurance exchanges open, news of glitches and delays abounds.

Yesterday’s Wall Street Journal noted several examples of how officials in Washington and the states have suffered new and significant problems implementing the law’s exchanges:

Colorado became the second state, after Oregon, to limit the ability of residents to enroll online in its state-run exchange in the first weeks, saying some people will have to enroll by phone or in person for about a month until glitches are ironed out.

In other words, for its grand opening next week, Colorado will rely on old-fashioned pen-and-paper applications for individuals interested in qualifying for coverage.

The exchange implementation failures have not been isolated, nor have they been limited to states. The Wall Street Journal reported in the same article yesterday that, “in another sign of the technical challenges” facing Obamacare, federally run exchanges in 33 states will not be able to sign applicants up for Medicaid coverage directly; instead, individuals will be sent to the state Medicaid agency to start the application process over again.

Late in the day yesterday came a separate story involving exchange delays and glitches, this one regarding the District of Columbia’s exchange:

The Obamacare exchange serving Washington, D.C. is delaying important parts of its operations less than a week before it is scheduled to open for enrollment. Washington’s exchange said Wednesday that it will not be ready on Oct. 1 to calculate the tax subsidies people can receive to help purchase private insurance. The D.C. exchange also will not immediately be able to determine eligibility for Medicaid.

So if you live in the District and qualify for exchange subsidies, the exchange won’t be able to determine what subsidy you’ll receive, and what you’ll actually pay for coverage—and if you think you might qualify for Medicaid, the exchange won’t be able to help you at all.

All these technical headaches might be enough to cause some Obamacare implementers to seek some “Obamacare” themselves. But the real headache will soon be facing the American people if Congress does not stop an increasingly unworkable law.

This post was originally published at The Daily Signal.

Obamacare’s Funny Money

This morning the New York Times reports on the confusion and uncertainty regarding Obamacare’s medical-loss ratio rebates.  Some individuals in employer plans have received notices that their plans will receive rebates – but the rebates are paid to the plans, and not the individuals, and many employers have not decided what to do with them.  This is perhaps unsurprising, because it may not be worth a business’ time and effort to distribute $1.51 rebate checks to all its employees – particularly given that the employee’s share of the premium can often be small.  So for both employer and employee, this supposed Obamacare “benefit” may end up being more hassle than it’s worth.

Meanwhile, the Washington Post’s fact checker column this morning gave President Obama three Pinocchios for making yet another misleading claim about Obamacare.  In Colorado this week, the President again repeated his old claim that Obamacare will lower premiums by creating Exchanges.  This claim essentially riffs off his discussion with Sen. Alexander back at the White House health summit in February 2010.  But as we demonstrated at the time, it wasn’t true then, and it isn’t true now.  Kessler cites numerous actuarial studies to make his point, but the gist is this:  Obamacare FORCES people to buy richer policies, and this Washington-mandated increase in benefits will raise premiums, not lower them.  Even Jonathan Gruber, who served as a paid consultant to HHS to create Obamacare, admits that the President’s rhetoric was misleading.

Four years ago, candidate Obama repeatedly promised that he would cut premiums – not slow the rate of growth, but CUT them in absolute terms – by $2,500 per family.  No amount of measly rebate checks, or misleading rhetoric, can hide the fact that Obamacare has, by the President’s own standards, spectacularly failed to deliver.

How You CAN’T Keep Your Current Coverage

In case you hadn’t seen it, the Galen Institute yesterday released a new paper discussing the havoc Obamacare is wreaking on insurance markets, and specifically the insurance many Americans had – and liked – before the massive 2700 page law was passed.  The paper includes the most comprehensive collection I have seen of anecdotes regarding insurance carriers who have dropped out of some markets, or gotten out of the health insurance industry completely, since Obamacare passed.  Below are the relevant excerpts from the Galen paper that tell the tale of Obamacare’s woes (I’ve edited the below lightly for length and by replacing citations with hyperlinks).  The complete list of companies that have dropped out of the insurance market shows the breathtaking scope of the impact this massive reorganization of health care is having on Americans’ lives.

Three years ago, candidate Obama promised that “you will not have to change plans.  For those who have insurance now, nothing will change under the Obama plan – except that you will pay less.”  And President Obama followed with the same pledge: “If you like your doctor, you will be able to keep your doctor.  Period.  If you like your health care plan, you will be able to keep your health care plan.  Period.  No one will take it away.  No matter what.”  The Galen report once again illustrates how hollow those pledges have proved.

 

The American Enterprise Group announced in October 2011 that it would stop offering non-group health insurance in more than 20 states.  As a result, 35,000 people will lose the health coverage they have now.  The company cited regulatory burdens, including the “medical loss ratio” (MLR) requirements (see page 4 for more), in explaining its decision to leave the markets.  This means there will be less competition in these 20 states, resulting in higher prices for consumers in many cases.

In New York, Empire BlueCross BlueShield said it will drop in the spring of 2012 health insurance plans covering about 20,000 businesses in the state. Mark Wagar, president and CEO of Empire, said that the company will eliminate seven of the 13 group plans it currently offers to businesses which have two to 50 employees.  The move is expected to have a great and potentially “catastrophic” impact on small businesses in New York, according to James L. Newhouse, president of Newhouse Financial and Insurance Brokers in Rye Brook, NY.  This loss of competition inevitably will lead to higher prices and fewer choices for businesses and their employees.

In Colorado, World Insurance Company/American Republic Insurance Company announced in October 2011 that it is leaving the individual market, citing the company’s inability to comply with insurance regulations.

In Indiana, nearly 10 percent of the state’s health insurance carriers have withdrawn from the market because they are unable to comply with the federal medical loss ratio requirement.  Indiana was hoping to bring the companies back by asking the Department of Health and Human Services (HHS) for a waiver from the rule, but Washington refused in late November 2011 to grant the waiver….

These are the latest in a series of announcements that health insurers are leaving the market as a result of ObamaCare’s edicts.  But there are many more.

The exodus continues

Citizens in states around the country have learned that carriers are leaving markets, largely as a consequence of the combined effect of the health law and state regulations that make it particularly difficult to offer coverage in the small group market.

Principal Financial Group, based in Iowa, announced in 2010 that it would stop selling health insurance, impacting 840,000 people who receive their insurance through employers served by the company.  The company assessed its ability to compete in the new environment created by PPACA and concluded its best course was to stop selling health insurance policies.

Another 42,000 employees of small and midsize employers learned in January 2011 they were losing their health coverage with Guardian Life Insurance Co. of America. The company announced it was leaving the group medical insurance market (it had reached an agreement with UnitedHealthcare to renew coverage for Guardian clients).  Guardian began withdrawing from the medical insurance market in specific states more than a decade ago, and says it would be leaving the market with or without PPACA.

Cigna announced that it is no longer offering health insurance coverage to small businesses in 16 states and the District of Columbia: California, Connecticut, Florida, Georgia, Hawaii, Illinois, Kansas, Missouri, New Hampshire, New York, North Carolina, Ohio, Pennsylvania, South Carolina, Texas, Virginia, and Washington, D.C.

In Colorado, Aetna will stop selling new health insurance to small groups in the state and is moving existing clients off its plans this year, affecting 1,200 companies and 5,200 employees and their dependents.   Aetna also has pulled out of Colorado’s individual market because of concerns about its ability to compete there, dropping 22,000 members.  Aetna also has dropped out of the small-group market in Michigan and several other states.

Since June of 2010, 13 plans have left the health insurance market in Iowa, citing regulatory concerns.

In New Mexico, four insurersNational Health Insurance, Aetna, John Alden, and Principal — are no longer offering insurance to individuals or to small businesses — drying up the market and driving out competition.

In Utah, Humana is ending its participation in the Utah Health Exchange, leaving only three carriers participating in the exchange.

In Virginia, UniCare has eliminated its individual market coverage for about 3,000 policyholders.  And shortly after the health law was enacted in

2010, a new Virginia-based company, nHealth, announced it was closing its doors, saying that the regulatory burdens posed by the health law made it impossible to gain investor support to continue operating.

It’s Medicare’s Open Season — So Where’s Andy Griffith?

Amidst the stories this week surrounding the CLASS Act debacle and the release of the final ACO reg, open season started for Medicare beneficiaries last Saturday.  Due to a provision in Obamacare, open season now starts a month earlier, and will end several weeks earlier as well.  And as a Kaiser Health News piece from last week cited one survey indicating that 65 percent of seniors were unaware of the changed dates for Medicare’s open season as of earlier this year.

This brings up the question I raised above:  Given the accelerated open season calendar, of which many seniors are unaware, where’s Andy Griffith to inform seniors of these important changes?  As you probably recall, last year CMS engaged Andy Griffith to take on the role of “pitching President Barack Obama’s health care law to seniors.”  Press reports note that the Administration spent $3 million in taxpayer funds to run an ad campaign in which Mr. Griffith was, in the White House’s own words, “delivering the good news” about Obamacare to seniors.  And according to CMS’ response to a Freedom of Information Act request, the ads were “only airing in September and October 2010” – i.e., the weeks and months right before November 2’s mid-term election.

My point is NOT to argue that at a time of trillion-dollar deficits, CMS should spend millions running television ads using “weasel words” and misleading rhetoric in an attempt to persuade seniors about Obamacare.  My question is, why is the Obama Administration running the Andy Griffith ad campaign in even-numbered years, but not odd-numbered ones?  Is timing such advertisements right around elections warranted or appropriate?  And does anyone want to venture a guess that an ad campaign featuring Mr. Griffith will return next fall in states like Florida, Colorado, and Ohio…?

Kaiser Health News: “New Plans for Uninsured Off to Slow Start”

Kaiser Health News published a story noting that “an unexpectedly small number of people” have signed up for the high-risk pool program established by the health care law.  “About 3,600 people have applied and about 1,200 have been approved so far in state plans,” with another 2,400 in plans operated by the federal government in 22 states.  “Connecticut could not provide an applicant total but said one person had been enrolled as of last week.”

State officials have been surprised by this poor showing for one of the health law’s “early deliverables.”  North Carolina’s pool director notes that “interest in the program has been lower than we expected;” Colorado’s risk pool director called her state’s enrollees a “very low number given that there are hundreds of thousands of uninsured in the state.”

But despite this low initial enrollment, the high-risk pool program could STILL run out of money before its scheduled end in 2014, as one expert quoted in the piece observed.  That’s because Democrats woefully under-funded the program – the Congressional Budget Office estimates by up to $10 billion – by choosing instead to fund backroom deals and “slush funds” for dubious new spending projects.

Many Republicans support high-risk pool programs to cover individuals with pre-existing conditions, but the Administration’s attempt to implement them seems to have fallen flat – thus far, many individuals aren’t getting covered, and those that do obtain insurance from the pools could have their coverage ended prematurely because Democrats failed to fund the pools adequately.  Either way, that’s not the type of health “reform” that those with pre-existing conditions deserve.

SCHIP Enrollment

Background:  The State Children’s Health Insurance Program, established under the Balanced Budget Act (BBA) of 1997, is a state-federal partnership originally designed to provide low-income children with health insurance—specifically, those children under age 19 from families with incomes under 200 percent of the federal poverty level (FPL), or approximately $40,000 for a family of four.  States may implement SCHIP by expanding Medicaid and/or creating a new state SCHIP program.  In addition, states may expand eligibility requirements by submitting state plan amendments and/or Section 1115 waiver requests to the Centers for Medicare and Medicaid Services (CMS).[1]  SCHIP received nearly $40 billion in funding over ten years as part of BBA, and legislation recently passed by Congress in December (P.L. 110-173) extended the program through March 2009, while providing additional SCHIP funds for states.

One concern of many conservatives regarding the SCHIP program relates to crowd-out—a phenomenon whereby individuals who had previously held private health insurance drop that coverage in order to enroll in a public program.  The Congressional Budget Office (CBO) analysis of H.R. 3963, a five-year SCHIP reauthorization which the President vetoed (and the House failed to override), found that of the 5.8 million children who would obtain Medicaid or SCHIP coverage under the legislation, more than one-third, or 2 million, would do so by dropping private health insurance coverage.

In order to prevent policies that encourage crowd-out, and ensure that SCHIP funds are more effectively allocated to the low-income beneficiaries for whom the program was created, CMS on August 17, 2007 issued guidance to state health officials about the way it would evaluate waiver proposals by states to expand their SCHIP programs.  Among other provisions, the letter stated that CMS would require states seeking to expand coverage to children with family incomes above 250% of FPL must first enroll 95% of eligible children below 200% of FPL, consistent with the original design and intent of the SCHIP program.  Congressional Democrats have introduced both a bill (H.R. 5998) and a joint resolution of disapproval under the Congressional Review Act (S. J. Res. 44) designed to repeal the Administration’s guidance.

Enrollment of Wealthier Children:  An analysis performed by the Congressional Research Service (CRS), using data provided by the Centers for Medicare and Medicaid Services (CMS), provides some indication of the extent to which states are focusing their efforts on enrolling poor children first before expanding their SCHIP programs up the income ladder.  Comparison of Fiscal Year 2006 and 2007 data reveal that in FY06, an estimated 586,117 children from families with incomes above 200% of the federal poverty level—approximately $41,000 for a family of four—were covered under SCHIP by a total of 15 states.

By contrast, in FY07, a total of 17 states and the District of Columbia covered an estimated 612,439 children in their SCHIP programs—an increase of nearly 30,000 children from wealthier families.  Much of this increase stems in part from decisions by three states—Maryland, Missouri, and Pennsylvania—along with the District of Columbia to extend SCHIP coverage to children with family incomes up to 300% of FPL during calendar year 2007, just prior to the release of the Administration’s SCHIP guidance.  In short, the data show no discernable trend by states to target their energies on enrolling lower-income children first before expanding SCHIP up the income scale—a key concern of many conservatives during the debate on children’s health legislation last year.

Enrollment of Adults in Children’s Program:  The CRS report also analyzes the coverage of adults—pregnant women, parents, and childless adults—in the SCHIP program.  The CRS data do indicate that the total number of adults decreased from FY06 to FY07, and the number of childless adults on the SCHIP rolls halved.  However, the number of states covering adults increased, and several states saw expansion of the number of adults, and childless adults, covered under the program:

  • Eight states—Arkansas, Colorado, Idaho, Illinois, Nevada, New Jersey, New Mexico, Oregon, and Virginia—saw overall adult populations in SCHIP increase;
  • Three states—Idaho, New Mexico, and Oregon—saw increased enrollment in the number of childless adults;
  • Seven states— Arizona, Arkansas, Idaho, Illinois, Nevada, New Jersey, New Mexico, and Oregon—saw increased enrollment in the number of parents covered;
  • Three states—Colorado, Nevada, and Rhode Island—increased SCHIP enrollment for pregnant women.

While many conservatives may support the overall reduction in adults enrolled in a children’s health insurance program, some may still be concerned by the persistence of adult coverage—particularly given decisions by both Arkansas and Nevada to expand coverage to adults during FY07.  In addition, the fact that nearly 75% of the reduction in adult SCHIP enrollment from FY06 to FY07 came from one state’s (Arizona) decision to remove childless adults from the program rolls may lead some conservatives to question whether this welcome development was a one-year anomaly or part of a larger trend.

Conclusion:  Most conservatives support enrollment and funding of the SCHIP program for the populations for whom the SCHIP program was created.  That is why in December the House passed, by a 411-3 vote, legislation reauthorizing and extending the SCHIP program through March 2009.  That legislation included an additional $800 million in funding for states to ensure that all currently eligible children will continue to have access to state-based SCHIP coverage.

However, many conservatives retain concerns about actions by states or the federal government that would reduce private health insurance coverage while increasing reliance on a government-funded program.  To that end, data proving that many states have expanded coverage to wealthier populations without first ensuring that low-income children are enrolled in SCHIP, and that states have in recent months expanded coverage under a children’s health insurance program to adult populations, suggest that some states continue to expand government-funded health insurance, at significant cost to state and federal taxpayers, in a manner that may encourage individuals to drop private coverage.

Particularly given these developments, conservatives may believe that the Administration’s guidance to states remains consistent with the goal of ensuring that SCHIP remains targeted toward the low-income populations for which it was designed.  Therefore, many conservatives will support the reasonable attempts by CMS to bolster the integrity of the SCHIP program while retaining state plans’ flexibility, and question efforts by Congressional Democrats to encourage further expansion of government-funded health insurance financed by federal taxpayers.

 

[1] In general, state plan amendments can expand eligibility to higher income brackets, or otherwise modify state plans, while Section 1115 waivers by definition require the Secretary of Health and Human Services to waive statutory requirements under demonstration authority.  For more information, see CRS Report RL 30473, available online at http://www.congress.gov/erp/rl/pdf/RL30473.pdf (accessed September 8, 2008).