Monthly Archives: March 2017
Insurance Coverage, Access to Care, and Medical Debt Since the ACA: A Look at California, Florida, New York, and Texas
Background
More than 30 million Americans now have health insurance under the provisions of the Affordable Care Act.1 These provisions include those that have allowed or encouraged people to enroll in coverage through expanded Medicaid eligibility, tax credits to help pay for premiums, state and federal outreach efforts, and consumer-friendly market regulations.2 A recent analysis found that the percentage of uninsured working-age adults dropped from 20 percent in 2010 to 12 percent in 2016.3
The law gives states flexibility in implementing provisions, including the choice of operating their own health insurance marketplace or leaving that task to the federal government. Moreover, in 2012, the U.S. Supreme Court gave states the option to decide whether or not to expand Medicaid eligibility to more lower-income adults. These choices, combined with each state’s unique demographics and history, have resulted in varying experiences among Americans. In this brief, we use data from the Commonwealth Fund Biennial Health Insurance Survey to examine differences in health insurance coverage, problems getting needed care because of costs, and medical bill and debt problems among 19-to-64-year-old adults in the nation’s four largest states: California, Florida, New York, and Texas.4
These states fall into two distinct categories. The first group, California and New York, both operate their own health insurance marketplaces and have expanded eligibility for Medicaid to adults with incomes at or below 138 percent of the federal poverty level—$16,394 for an individual or $33,534 for a family of four. Florida and Texas, the second group, are using the federal marketplace to enroll residents in health plans and have declined to expand Medicaid eligibility (Exhibit 1).
Conclusion
The Affordable Care Act has significantly affected health insurance coverage and access among U.S. adults. But the decisions made by state leaders in implementing federal policy, along with other state laws, have ongoing implications for their residents. California and New York began seeing declines in their adult uninsured rate earlier than other states because of such choices. California expanded eligibility for Medicaid even before 2014 by creating the Low Income Health Program, which provided coverage to adults with incomes less than 200 percent of poverty.20 New York expanded Medicaid eligibility to parents with incomes up to 150 percent of poverty and childless adults up to 100 percent of poverty starting in 2000.21 In addition, both states opted to establish their own marketplaces and have conducted expansive outreach campaigns to increase awareness of coverage options. Alternatively, Florida and Texas—although they have experienced robust enrollment in private plans through the federal health insurance marketplace—have not expanded Medicaid eligibility and have made less progress covering uninsured residents.
However, the variation in insured rates is not entirely the result of states’ decision. The ACA does not provide access to any new coverage options for undocumented immigrants. They are ineligible for Medicaid coverage and cannot purchase private plans through the marketplace, subsidized or unsubsidized. This is likely a contributing factor in Texas’s higher uninsured rate.
While expanded coverage is the necessary first step to improving timely access to care and reducing medical financial burdens among U.S. families, the quality and comprehensiveness of coverage across all sources of insurance—marketplace plans, individual market plans, employer-provided coverage, and Medicaid—also has a significant impact.
The gains documented in this survey and many other private and federal analyses indicate that the Affordable Care Act has been successful in insuring millions of Americans and enabling them to get health care they may not have been able to afford previously. Further expanding coverage and improving affordability should remain a priority. Alternatively, repealing the law without a replacement that is at least equally effective will risk reversing the substantial gains the nation has made.
Faith-based providers likely to keep pension regulation exemptions
The U.S. Supreme Court on Monday appeared skeptical of arguments that they should subject faith-based health systems to federal pension regulations.
The eight justices considered three cases on Monday involving Advocate Health Care, St. Peter’s Healthcare System and Dignity Health where federal appeals courts determined the faith-based systems did not qualify for a so-called “church plan” exemption from the Employee Retirement Income Security Act. For three decades, the Internal Revenue Service, Department of Labor and Pension Benefit Guaranty Corp. have treated faith-based organizations’ pension plans as exempt from ERISA.
If the appellate decisions are upheld, the health systems and other large and small faith-based organizations will have to comply with ERISA’s disclosure rules, fully fund their pension plans and pay PBGC premiums. The decision could affect the retirement benefits of more than a million employees around the country.
The systems say their pensions are well funded but a ruling against them could force them to pay billions in penalties in the lawsuits. The systems have said that would result in them being able to provide less charity care or eliminate their pension plans altogether.
“Countless” pension plans have been structured based on faith-based organizations’ beliefs that they fell under this church plan exemption, relying on hundreds of letters from the Internal Revenue Service, Department of Labor and PBGC that affirmed that status, according to the health systems’ counsel Lisa Blatt. Reversing that longstanding practice would “unleash a torrent of unintended consequences,” she told the eight justices.
The health systems have argued that Congress intended to allow church agencies – including health systems, schools and other organizations supporting the church’s religious mission – to create their own ERISA-exempt pension plans.
Although several justices questioned whether the underlying congressional statute supports that argument, Chief Justice John Roberts and Justice Sonia Sotomayor both pointed out that the federal agencies obviously had a similar reading of the law.
Similarly, Justice Anthony Kennedy noted the faith-based systems relied in good faith on the federal agencies’ interpretation.
But pension beneficiaries are concerned that this provides massive corporations like Dignity – one of the largest health systems in the country – with an unfair advantage over its competitors that Congress never intended. Faith-based organizations don’t have to insure their plan’s benefits, meet ERISA vesting requirements or clarify rights to future benefits.
“(Congress) wanted a close tie between the church and plan,” the beneficiaries’ counsel James Feldman said during oral arguments Monday. If the church isn’t involved in the pension plan, there’s no reason an organization should receive ERISA exemption, he said.
The federal government has sided with the hospitals, with Deputy Solicitor General Malcolm Stewart telling the justices that Congress expanded the church plan exemption in the 1980s to include church-affiliated organizations’ pension plans after the IRS denied an exemption in the 1970s.
How do Americans feel about single-payer health care? It’s complicated.
In the wake of the collapse of the Republican health-care proposal on Friday, there was an instantaneous effort by the progressive left to pick up the fumble and return it for a touchdown. As The Washington Post’s Dave Weigel reported, some Democrats quickly saw the failure as an opportunity to advance a long-held objective: a national, single-payer, health-care system matching those in countries such as Canada and Britain.
That effort was bolstered by tweets like this one, from progressive filmmaker Michael Moore.
“Remember this poll,” he tweeted, “the majority AGREE!”
But it’s not that simple.
Moore links to an article from The Post published in May, as the Democratic nominating contest was wrapping up. That article looked at polling from Gallup that presented respondents with a series of nonexclusive options for how the American health-care system might move forward: federally centralized health care, a repeal of the Affordable Care Act (i.e., Obamacare) or keeping Obamacare as the system.
Of those three, federally funded health care — that is, single-payer — was the most popular, with 58 percent support.
In Health Bill’s Defeat, Medicaid Comes of Age
When it was created more than a half century ago, Medicaid almost escaped notice.
Front-page stories hailed the bigger, more controversial part of the law that President Lyndon B. Johnson signed that July day in 1965 — health insurance for elderly people, or Medicare, which the American Medical Association had bitterly denounced as socialized medicine. The New York Times did not even mention Medicaid, conceived as a small program to cover poor people’s medical bills.
But over the past five decades, Medicaid has surpassed Medicare in the number of Americans it covers. It has grown gradually into a behemoth that provides for the medical needs of one in five Americans — 74 million people — starting for many in the womb, and for others, ending only when they go to their graves.
Medicaid, so central to the country’s health care system, also played a major, though far less appreciated, role in last week’s collapse of the Republican drive to repeal and replace the Affordable Care Act, also known as Obamacare. While President Trump and others largely blamed the conservative Freedom Caucus for that failure, the objections of moderate Republicans to the deep cuts in Medicaid also helped doom the Republican bill.
“I was not willing to gamble with the care of my constituents with this huge unknown,” said Representative Frank A. LoBiondo of New Jersey, a member of the centrist Tuesday Group caucus, noting that in three of the counties in his district in the state’s more conservative southern half, over 30 percent of all residents are covered by Medicaid.
In the Senate, many Republicans, echoing their states’ governors, had worried about jeopardizing the treatment of people addicted to opioids, depriving the working poor, children and people with disabilities of health care and in the long run reducing funding for the care of elderly people in nursing homes.
The Republican bill would have largely undone the expansion of Medicaid under the A.C.A., which added 11 million low-income adults to the program and guaranteed the federal government would cover almost all of their costs. It would have also ended the federal government’s open-ended commitment to pay a significant share of states’ Medicaid costs, no matter how much enrollment or spending rose. Instead, the bill would have given the states a choice between a fixed annual sum per recipient or a block grant, both of which would have almost certainly led to major cuts in coverage over time.
The nonpartisan Congressional Budget Office predicted that the Republican bill would have cumulatively cut projected spending on Medicaid by $839 billion and reduced the number of Medicaid beneficiaries by 14 million over the coming decade.
What Happens Next for the ACA?
http://takecareblog.com/blog/what-happens-next-for-the-aca
In his speech after withdrawing the Republican health care bill from consideration on Friday, Speaker of the House Paul Ryan said that “Obamacare is the law of the land” and will remain so “for the foreseeable future.” But law professors who have followed the Affordable Care Act (ACA) for the past seven years ago know that its future is not yet secure. President Trump has said that “the best thing we can do politically speaking is let Obamacare explode,” and there’s a lot he can do to make that explosion a reality.
It doesn’t have to come to that. Contrary to GOP reports, the ACA is not collapsing. The Medicaid expansion will continue chugging along and we’re even seeing other states—Kansas and North Carolina most recently—move toward their own expansions. The individual markets in some states are fragile, but they are not in a death spiral. As the Congressional Budget Office noted in its first score of the GOP bill just two weeks ago, the marketplaces would “probably be stable in most areas” under current law.
Without question, however, President Trump and HHS Secretary Price have the ability to radically destabilize the individual marketplace. The only question is whether they attempt to do so through active sabotage, incompetence, or purposeful ambivalence.
One of us (Nick Bagley), along with Harvard PhD student Adrianna McIntyre, has already compiled a preliminary list of executive actions President Trump could take that would reshape the ACA. Many of these will not be news, but we write here to focus on two actions with the greatest potential to disrupt the market: ending cost-sharing payments to insurers and declining to enforce the individual mandate.
The largest concern facing the individual markets is the fate of House v. Price, a lawsuit brought by the House of Representatives against President Obama’s HHS Secretary (Sylvia Burwell) in 2014. The House argued that the administration was acting illegally in making cost-sharing payments to insurers because Congress had not specifically appropriated those funds. A judge on the District Court for the District of Columbia ruled both that the House had standing to sue (wrong) and that the administration’s spending violated the Appropriations Clause (right).
The Obama administration appealed the case to the DC Circuit, but, of course, on November 7, 2016, there was an intervening event: the election of President Trump. The GOP-led House then asked the court to stay the litigation to see what the future might hold for health reform. The case is being held in abeyance, with the next status report due at the end of May, just days before insurers must file their insurance plans for 2018.
Here’s why the case is such a big deal for the individual markets: The ACA instructs insurers to limit the out-of-pocket expenses for enrollees who make less than 250% of the federal poverty level. This cost-sharing cap thus plays a key role in keeping insurance affordable for the low-income population. The federal government is then supposed to reimburse insurers for cutting those low-income customers a break.
Cartoon – We’ve caught it early
Cartoon – Ain’t It the Truth?
Cartoon – The Power of the Committee
More States To Expand Medicaid Now That Obamacare Remains Law
More states will pursue expansion of Medicaid health benefits for poor Americans under the Affordable Care Act after Republicans failed to repeal and replace the law.
The American Health Care Act, also known as Trumpcare, would’ve rolled back the ACA’s Medicaid expansion and put restrictions on states that tried to expand such coverage. But Speaker of the U.S. House of Representatives Paul Ryan Friday pulled the ACHA legislation Friday, making, “Obamacare the law of the land,” as he said.
At least two states– Kansas and North Carolina–are already working toward becoming the 32nd and 33rd states to expand Medicaid under the ACA. They would join 31 states plus the District of Columbia that have taken advantage of generous federal funding available under the law, President Obama’s signature legislative achievement, according to the Advisory Board.
And there may be even more states that will resurrect state legislative efforts to expand Medicaid. Before Trump was elected, Georgia, Idaho, Nebraska and South Dakota were considering Medicaid expansion. But Trump’s election, along with Republican control of Congress, prompted these states to put on the brakes for Medicaid expansion when an ACA repeal looked likely. “The effort to expand Medicaid in Georgia just died,” the Atlanta Journal-Constitution said Nov. 9, 2016, the day after Trump won the electoral college.
From 2014 through 2016, the ACA’s Medicaid expansion population is funded 100% with federal dollars. Beginning this year, states gradually have to pick up some costs, but the federal government still picks up 90% or more of Medicaid expansion through 2020. It was a better deal than before the ACA, when Medicaid programs were funded via a much less generous split between state and federal tax dollars.
With the federal funding still part of the ACA, Kansas lawmakers just last week were forging ahead and now have a hurdle lifted with the law in place for the “foreseeable” future, as Speaker Ryan said. A so-called “manager’s amendment” in Ryan’s failed ACHA bill took specific aim at Kansas and North Carolina, making the states “long shots” at expanding Medicaid until Friday’s failed Obamacare repeal.
HENRY KOTULA 