Poster #140 - Health Care Handcuffed: ERISA Preemption’s Unyielding Grip on State Health Laws

• In Event: Friday Poster Reception

Abstract

Health insurance coverage delays and denials are a uniquely American experience, leading to patient frustrations highlighted perhaps most clearly in the aftermath of the December 4, 2024 assassination of UnitedHealthcare CEO Brian Thompson as patients across the country took to social media about delays and denials of coverage at the hands of private insurers. What appeared at first blush to be a unique opportunity – or “critical juncture” – in which to pursue belated health insurance reform, the political climate was ultimately not conducive to such change. In fact, the results of the 2024 presidential election signal an acceleration of reliance on private health insurance, in which many of these coverage barriers arise as private insurers fulfill fiduciary responsibilities to shareholders. Thus, it is especially important to better appreciate the legal and political context that drives health insurance barriers – namely, the key role of the Employee Retirement Income Security Act of 1974, more commonly known as ERISA – and how it impedes health care access and equity. While my forthcoming book Coverage Denied: How Health Insurers Drive Inequality in the United States offers the first comprehensive elucidation of the scale of health insurance coverage barriers, the legal underpinnings and effects on American federalism are considerably less well understood. Accordingly, drawing on the lenses of American political economy, health policy, and law, I examine ERISA’s shortcomings in its intersection with health policy and its reshaping of America’s health federalism in ways that prove consequential.  Though ERISA’s role in labor politics has been well studied, the health side is considerably less well-understood, but it operates a key driver of health and health insurance inequity for two reasons. First, it virtually denies legal recourse to patients who have been denied coverage by their self-insured health plans, which undercuts health insurer accountability and makes it particularly taxing for less affluent patients to pursue justice in the face of insurance barriers. Second, it preempts state policies that “relate to” self-insured health plans, which cover approximately 100 million patients, such that any efforts that states take to promote health insurance access and reduce health insurance inequity will not be felt by the majority of people enrolled in ESI.  While other chapters of this book examine the political history and legal implications, this article focuses on ERISA preemption’s disruption of traditional conceptions of health federalism. It introduces a new dataset of 4,469 state laws (identified by the National Conference on State Legislatures) that relate to health insurance – prior authorization reform, pharmaceutical coverage policies and PBM reforms, telemedicine, mental health and substance use disorder benefits, and beyond – and describes through textual analysis of the laws and their legislative history the critical ways that ERISA mutes these laws’ effects. Of course, federalism is a double-edged sword, so the analysis assesses the extent to which ERISA impedes more comprehensive reform efforts for better and worse. It observes both macro-level trends in state health lawmaking as well as gleaning insights from closer analyses of a subset of state laws within these policy domains.

Author

• Miranda Elyse Yaver, University of Pittsburgh
  Presenting Author