Topics: Medicare, Politics
Officials at the Centers for Medicare & Medicaid Services are proposing to remove some drugs from Medicare’s prescription drug plans and limit how many plans insurers can offer. KHN’s Mary Agnes Carey and CQ Roll Call’s Emily Ethridge discuss.
>> Click here to listen to audio of the conversation.
MARY AGNES CAREY: Welcome to Health on the Hill. I’m Mary Agnes Carey.
A series of proposed changes to the Medicare prescription drug program -- also known as Medicare part D -- have been getting a lot of attention on and off of Capitol Hill. Patient groups and lawmakers in both parties say easing current requirements on what drugs plan must cover could cause hardships for some patients. There’s also bipartisan opposition to a provision that would limit the number of plans insurers could offer.
With me now to discuss these issues is Emily Ethridge of CQ Roll Call. Emily, thanks so much for coming.
EMILY ETHRIDGE, CQ ROLL CALL: Thanks for having me.
MARY AGNES CAREY: Now CMS currently -- that’s the Centers for Medicare & Medicaid Services, which oversees the Medicare part D program -- they currently require that Part D plans cover the vast majority of drugs in six specific classes. And they’re proposing to drop two of these categories next year, and another might be dropped in 2015. What are these drugs that could lose this "protected status," as they call it, and why are people so concerned about it?
EMILY ETHRIDGE: The drugs that CMS is proposing to remove from this requirement to offer are anti-depressants and immunosuppressant drugs, and the one that they’re thinking about doing later are anti-psychotic drugs. So we’ve had a lot of outcry from patient groups for the communities that take these medications saying we’ve been able to have access to all these drugs before on all our Medicare plan formularies, now we’re really worried this is going to reduce our access and reduce our ability to get the drugs we need. They really make the point that these drugs aren’t all the same. So it’s important to have a wide range of availability.
MARY AGNES CAREY: What’s CMS’s response? What’s the rationale for doing this?
EMILY ETHRIDGE: The CMS administrators have said, "We don’t have any problems with the other drugs that aren’t in these protective classes," as they call them.
There are about 140 classes of drugs that Medicare has on its formulary plan. And there are only six that are in the special categories. They’re saying "If you don’t have a problem with the other 134, we shouldn’t have any problems with a couple of these."
MARY AGNES CAREY: Did they also suggest that plans have some issue in that they can’t really leverage a discount with a drug maker if they have to offer a wide array?
EMILY ETHRIDGE: Right. If you have to offer, on your plan, every single antidepressant that’s available for purchase, it makes it really hard for you to negotiate because the drug maker knows you’re required to offer that drug so they can sell it to you at a higher price.
MARY AGNES CAREY: Currently, Medicare beneficiaries who are in Part D have something like three-dozen plans, in a particular region, to choose from. CMS is proposing some limits to those number of plan offerings. Why are they doing that?
EMILY ETHRIDGE: CMS says that’s because, right now, there are just too many plans. Seniors are confused. Do they have such an overwhelming amount of information on all these plans, that it’s really hard to make a good choice? They’re not going to sit down and compare 36 plans to pick the right one. They say seniors really don’t even move plans that much, even though they have this wide array of options. They tend to stick with one and stay with it not take advantage of these different options they have.
MARY AGNES CAREY: So the idea is that these plans are somewhat duplicative and if you narrowed the choices, then people might do more comparison shopping? Is that the thought?
EMILY ETHRIDGE: Right, it's can you make a smarter, better decision? Can you make this decision process easier for a senior? If you’re comparing plan one to plan two, that should be a lot simpler. It’s easier to see the differences than if you’re comparing plans one through 36.
MARY AGNES CAREY: We’ve talked about two of the proposals in this regulation. It’s a pretty big regulation. What are some of the areas that are causing some concern on the Hill?
EMILY ETHRIDGE: There is another area that is really important, which is about preferred pharmacy networks. The rule says that a plan would have to allow any pharmacy that’s willing to meet its price to participate in its preferred network. Right now plans sort of negotiate with -- and they have a certain particular pharmacy. They say you get a better deal if you go to this pharmacy. They offer better prices, because they negotiated something together.
CMS would say: If any pharmacy comes to you and offers to meet the terms of that deal, you must accept it.
MARY AGNES CAREY: Emily, one thing I’ve been wondering about this is: We know that the administration is currently embroiled in a big battle on Capitol Hill over the Affordable Care Act and its implementation. Now this particular proposal is also causing a lot of concern -- not only with Republicans but Democrats, as well.
Why do you think CMS made this proposal at this time?
EMILY ETHRIDGE: It is confusing, because it is a lot of change at a time when the Medicare situation is already changing. We heard a lot from the CMS officials about price and the cost of Medicare Part D, which covers prescription drugs. It’s increasing much higher than the rest of Medicare. They say this proposed rule would actually save money over ten years. And they say it would make things simpler for seniors.
They say that because of the law, in some cases, we don’t need, maybe, this many plans. The health care law is reducing that prescription drug doughnut hole, that coverage gap that we’ve all heard so much about. If that’s being made smaller, then we don’t need all these plans to fill that in -- we don’t need all these choices, and we don’t need spend money on all of these options. It’s just not necessary.
MARY AGNES CAREY: Thanks for bringing us up to date, Emily Ethridge of CQ Roll Call.
Topics: Politics, Health Reform, Insurance, Marketplace, Women's Health
President Obama used Tuesday night's annual State of the Union address to urge more Americans to enroll in the new insurance exchanges.
The video excerpt above includes the president's remarks about health policy and the rollout of the 2010 health law.
A transcript follows.
PRESIDENT BARACK OBAMA: One last point on financial security. For decades, few things exposed hard-working families to economic hardship more than a broken health care system. And in case you haven’t heard: We’re in the process of fixing that.
A pre-existing condition used to mean that someone like Amanda Shelley, a physician assistant and single mom from Arizona, couldn’t get health insurance. But on January 1, she got covered. On January 3, she felt a sharp pain. On January 6, she had emergency surgery. Just one week earlier, Amanda said, that surgery would have meant bankruptcy.
That’s what health insurance reform is all about: the peace of mind that if misfortune strikes, you don’t have to lose everything.
Already, because of the Affordable Care Act, more than three million Americans under age 26 have gained coverage under their parents’ plans.
More than nine million Americans have signed up for private health insurance or Medicaid coverage. Nine million.
And here’s another number: zero. Because of this law, no American - none, zero - can ever again be dropped or denied coverage for a preexisting condition like asthma, or back pain, or cancer. No woman can ever be charged more just because she’s a woman. And we did all this while adding years to Medicare’s finances, keeping Medicare premiums flat, and lowering prescription costs for millions of seniors.
Now, I don’t expect to convince my Republican friends on the merits of this law. But I know that the American people aren’t interested in refighting old battles. So again, if you have specific plans to cut costs, cover more people, and increase choice – tell America what you’d do differently. Let’s see if the numbers add up. But let’s not have another forty-something votes to repeal a law that’s already helping millions of Americans like Amanda. The first forty were plenty. We all owe it to the American people to say what we’re for, not just what we’re against.
And if you want to know the real impact this law is having, just talk to Gov. Steve Beshear of Kentucky, who’s here tonight. Now, Kentucky is not the most liberal part of the country. That's not where I got my highest vote totals. But he’s like a man possessed when it comes to covering his commonwealth’s families. “They are our friends and neighbors,” he said. “They are people we shop and go to church with: farmers out on the tractors, grocery clerks. They are people who go to work every morning praying they don’t get sick. No one deserves to live that way.”
Steve’s right. That’s why, tonight, I ask every American who knows someone without health insurance to help them get covered by March 31. Help them get covered. Moms, get on your kids to sign up. Kids, call your mom and walk her through the application. It'll give her some peace of mind – plus, she’ll appreciate hearing from you.
President Obama announced Thursday that insurers will be permitted to extend canceled insurance policies into 2014, due to the difficulties consumers are having enrolling in new insurance coverage through the new online marketplaces.
More coverage: Obama Offers Fix For Insurance Plan Cancellations
PRESIDENT BARACK OBAMA: ... It has now been six weeks since the Affordable Care Act's new marketplaces opened for business. I think it's fair to say that the roll out has been tough so far, and I think everybody understands that I'm not happy about the fact that the roll out has been, you know, wrought with a whole range of problems that I've been deeply concerned about.
But today, I want to talk about what we know after these first few weeks and what we're doing to implement and improve the law. Yesterday, the White House announced that in the first month more than 100,000 Americans successfully enrolled in new insurance plans.
Is that as high a number as we'd like? Absolutely not.
But, it does mean that people want affordable health care. The problems of the website have prevented too many Americans from completing the enrollment process, and that's on us, not on them. But, there's no question that there's real demand for quality affordable health insurance.
In the first month, nearly a million people successfully completed an application for themselves or their families, those applications represent more than 1.5 million people. Of those 1.5 million, 106,000 of them have successfully signed up to get covered. Another 396,000 have the ability to gain access to Medicaid under the Affordable Care Act. That's been less reported on, but it shouldn't be. Americans who are having a difficult time, who are poor, many of them working, may have a disability -- they're Americans like everybody else. And the fact that they are now able to get insurance is going to be critically important.
Later today, I'll be in Ohio where Governor Kasich, a Republican, has expanded Medicaid under the Affordable Care Act. And as many as 275,000 Ohioans will ultimately be better off because of it. And if every governor followed suit, another 5.4 million Americans could gain access to health care next year.
So, the bottom line is in just one month, despite all the problems that we've seen with the website, more than 500,000 Americans could know the security of health care by January 1, many of them for the first time in their lives. And that's life-changing and it's significant.
That still leaves about 1 million Americans who successfully made it through the website, now qualified by insurance, but haven't picked a plan yet. And there's no question that if the website were working as it's supposed to, that number would be much higher of people who've actually enrolled. So that's problem number one, making sure that the website works the way it's supposed to.
It's gotten a lot better over the last few weeks than it was on the first day, but we're working 24/7 to get it working for the vast majority of Americans in a smooth, consistent way.
The other problem that has received a lot of attention concerns Americans who've received letters from their insurers that they may be losing the plans they bought in the old individual market, often because they no longer meet the law's requirements to cover basic benefits like prescription drugs or doctor's visits.
Now, as I indicated earlier, I completely get how upsetting this can be for a lot of Americans, particularly after assurances they heard from me that if they had a plan that they liked, they could keep it.
And, to those Americans, I hear you loud and clear. I said that I would do everything we can to fix this problem, and today I'm offering an idea that will help do it.
Already, people who have plans that pre-date the Affordable Care Act can keep those plans, if they haven't changed. That was already in the law. That's what's called a grandfather clause. It was included in the law.
Today, we're gonna extend that principle both to people whose plans have changed since the law took effect and to people who bought plans since the law took effect.
So state insurance commissioners still have the power to decide what plans can and can't be sold in their states, but the bottom line is insurers can extend current plans that would otherwise be canceled into 2014, and Americans whose plans have been canceled can choose to re-enroll in the same kind of plan.
We're also requiring insurers to extend current plans to inform their customers about two things. One, what protections these renewed plans don't include. Number two, that the marketplace offers new options with better coverage and tax credits that might help you bring down the cost.
So, if you received one of these letters, I'd encourage you to take a look at the marketplace. Even if the Web site isn't working as smoothly as it should be for everybody yet, the plan comparison tool that lets you browse costs for new plans near you is working just fine.
Now, this fix won't solve every problem for every person. But it's gonna help a lot of people. Doing more will require work with Congress. And I've said from the beginning, I'm willing to work with Democrats and Republicans to fix problems as they arise. This is an example of what I was talking about. We can always make this law work better.
It is important to understand, though, that the old individual market was not working well. And it's important that we don't pretend that somehow that's a place worth going back to. Too often, it works fine, as long as you stay healthy. It doesn't work well when you're sick.
So year after year, Americans were routinely exposed to financial ruin or denied coverage due to minor pre-existing conditions or dropped from coverage altogether, even if they paid their premiums on time. That's one of the reasons we pursued this reform in the first place. And that's why I will not accept proposals that are just another brazen attempt to undermine or repeal the overall law and drag us back into a broken system.
We will continue to make the case -- even the folks who choose to keep their own plans -- that they should shop around in the new marketplace, because there's a good chance that they'll be able to buy better insurance at lower cost.
So we're going to do everything we can to help the Americans who've received these cancellation notices. But I also want everybody to remember, there are still 40 million Americans who don't have health insurance at all. I'm not going to walk away from 40 million people who have the chance to get health insurance for the first time, and I'm not going to walk away from something that has helped the cost of health care grow at its slowest rate in 50 years.
So we're at the opening weeks of the project to build a better health care system for everybody, a system that will offer real financial security and peace of mind to millions of Americans.
It is a complex process. There are all kinds of challenges. I'm sure there will be additional challenges that come up. And it's important that we're honest and straightforward in terms, when we come up with a problem with these reforms and these laws, that we address them.
But we've got to move forward on this. It took 100 years for us to even get to the point where we could start talking about and implementing a law to make sure everybody's got health insurance. And my pledge to the American people is, is that we're going to solve the problems that are there, we're going to get it right, and the Affordable Care Act is going to work for the American people.
Topics: Health Reform, Politics, Insurance, Marketplace
President Barack Obama discussed the rollout of the federal health law in a White House speech Monday. In the excerpt above, he discusses the technical problems with the federal health insurance marketplace website and what his administration is doing to help consumers get enrolled in an insurance plan.
PRESIDENT BARACK OBAMA: The point is the essence of the law -- the health insurance that's available to people -- is working just fine. In some cases, actually, it's exceeding expectations. The prices are lower than we expected, the choice is greater than we expected.
But the problem has been that the website that's supposed to make it easy to apply for and purchase the insurance is not working the way it should for everybody. And there's no sugarcoating it. The website has been too slow. People have been getting stuck during the application process. And I think it's fair to say that nobody is more frustrated by that than I am, because -- precisely because the product is good, I want the cash registers to work, I want the checkout lines to be smooth because I want people to be able to get this great product.
And there's no excuse for the problems. And these problems are getting fixed. But while we're working out the kinks in the system, I want everybody to understand the nature of the problem.
First of all, even with all the problems at healthcare.gov, the website is still working for a lot of people, just not as quick or efficient or consistent as we want.
And although many of these folks have found that they had to wait longer than they wanted, once they complete the process, they're very happy with the deal that's available to them, just like Janice is.
Second, I want everybody to remember that we're only three weeks into a six-month open enrollment period when you can buy these new plans.
Keep in mind, the insurance doesn't start until Jan. 1. That's the earliest that the insurance can kick in. No one who decides to purchase a plan has to pay their first premium until Dec. 15. And unlike the day after Thanksgiving sales for the latest Play Station or flatscreen TVs, the insurance plans don't run out. They're not going to sell out. They'll be available through the marketplace throughout the open-enrollment period. The prices that insurers have set will not change. So everybody who wants insurance through the marketplace will get insurance. Period. Everybody who wants insurance through the marketplace will get insurance.
Third, we are doing everything we can possibly do to get the websites working better, faster, sooner. We've got people working overtime, 24/7, to boost capacity and address the problems. Experts from some of America's top private sector tech companies who, by the way, have seen things like this happen before -- they want it to work. They're reaching out; they're offering to send help.
We've had some of the best I.T. talent in the entire country join the team. And we're well into a tech surge to fix the problem. And we are confident that we will get all the problems fixed.
Number four, while the website will ultimately be the easiest way to buy insurance through the marketplace, it isn't the only way. Now, I want to emphasize this: Even as we redouble our efforts to get the site working as well as it's supposed to, we're also redoubling our efforts to make sure you can still buy the same quality, affordable insurance plans available on the marketplace the old- fashioned way, off-line, either over the phone or in person.
And, by the way, there are a lot of people who want to take advantage of this who are more comfortable working on the phone, anyway, or in person.
So, let me go through the specifics as to how you can do that, if you're having problems with the website, or you just prefer dealing with a person.
Yesterday, we updated the website's home page to offer more information about the other avenues to enroll in affordable health care until the online option works for everybody. So, you'll find information about how to talk to a specialist who can help you apply over the phone, or to receive a downloadable application you can fill out yourself and mail in.
We've also added more staff to the call centers where you can apply for insurance over the phone. Those are already, they've been working, but a lot of people have decided first to go to the website.
But keep in mind, these call centers are already up and running. And you can get your questions answered by real people 24 hours a day, in 150 different languages.
The phone number for these call centers is 1-800-318-2596. I want to repeat that, 1-800-318-2596.
Wait times have averaged less than one minute so far on the call centers, although I admit that the wait times probably might go up a little bit now that I've read the number out loud on national television.
But the point is, the call centers are available. You can talk to somebody directly, and they can walk you through the application process. And I guarantee, if one thing's worth the wait it's the safety and security of health care that you can afford or the amount of money that you can save by buying health insurance through the marketplaces.
Once you get on phone with a trained representative, it usually takes about 25 minutes for an individual to apply for coverage, about 45 minutes for a family. Once you apply for coverage, you'll be contacted by mail -- by email or postal mail about your coverage status.
But you don't have to just go through the phone. You can also apply in person with the help of local navigators. These are people especially trained to help you sign up for health care and they exist all across the country. Or you can go to community health centers and hospitals.
Just visit localhelp.healthcare.gov to find out where in your area you can get help and apply for insurance in person.
And finally, if you've already tried to apply through the website and you've been stuck somewhere along the way, do not worry. In the coming weeks, we will contact you directly, personally with a concrete recommendation for how you can complete your application, shop for coverage, pick a plan that meets your needs and get covered once and for all.
So here's the bottom line: the product, the health insurance is good. The prices are good. It is a good deal. People don't just want it, they're showing up to buy it. Nobody is madder than me about the fact that the website isn't working as well as it should, which means it's going to get fixed.
And in the meantime, you can bypass the website and apply by phone or in person. So don't let problems with the website deter you from signing up or signing your family up or showing your friends how to sign up, because it is worth it. It will save you money. If you don't have health insurance, if you've got a pre-existing condition, it will save you money, and it will give you the security that your family needs.
In fact, even with the website issues, we've actually made the overall process of buying insurance through the marketplace a lot smoother and easier than the old way of buying insurance on your own. Part of the challenge here is that a lot of people may not remember what it's like to buy insurance the traditional way.
The way we've set it up, there are no more absurdly long application forms, there's no medical history questionnaire that goes on for pages and pages, there's no more getting denied because you've had a pre-existing condition. Instead of contacting a bunch of different insurers one at a time, which is what Janice and a lot of people who were shopping on the individual market for health insurance had to do, there's one single place you can go shop and compare plans that have to compete for your business. There's one single phone number you can call for help.
And once the kinks in the website have been ironed out, it will be even smoother and even easier. But in the meantime, we will help you sign up, because consumers want to buy this product and insurance companies want to sell it to you.
Topics: Health Reform, Marketplace, Insurance, Insuring Your Health
Insuring Your Health columnist Michelle Andrews helps you navigate the new insurance marketplaces that are scheduled to launch on Oct. 1.
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Q: Do I have to buy through the marketplace or can I get my insurance on the private market?
A: If you have good coverage available to you, either through your job, Medicare or Medicaid, you probably won’t need to shop for coverage through a marketplace. If you don’t have such coverage though, in most states you'll be able to look for coverage either through the marketplace or on the private market next year. The District of Columbia and Vermont are the only exceptions; all of their individual and small-group policies will be sold through the exchanges.
In other states, new individual and small-group plans sold on the exchanges or in the private market must all cover the same package of 10 essential health benefits and conform to the same cost-sharing standards. But premium tax credits and cost-sharing subsidies that will make coverage more affordable will only be available for plans purchased through the marketplaces. That's worth keeping in mind.
If you make more than 400 percent of the federal poverty level-about $46,000 for an individual or $94,000 for a family of four, you won't be eligible for subsidies on the exchanges and may want to shop there and in the private market. If you're currently insured and you want to hang onto the plan you have, you can do that on the private market as well.
More From This Series: Shopping For Coverage
More Consumer Topics: Insuring Your Health
Q: How many choices will consumers have in a marketplace? Will PPOs and HMOs be included?
A: The number of plans that consumers will have to choose from is likely to vary widely. In some states, only a couple of insurers have announced plans to offer policies though the marketplace, while in others there may be a dozen or more. Even within a state, there will be differences in the number of plans available in different areas. You can expect that insurers will offer a variety of types of plans, including familiar models like PPOs and HMOs.
There will be some important differences, however. All of the plans sold on the exchanges will offer a similar package of 10 essential health benefits that provide comprehensive coverage. How much consumers will owe in cost sharing will vary depending on which of four types of plan they choose.
In a platinum plan, the most generous plan offered, the insurer will pay 90 percent of covered medical expenses and the consumer will be responsible for 10 percent, on average. In a gold plan, the insurer will pay 80 percent and the consumer 20 percent. Silver plans will pay 70 percent and bronze plans 60 percent.
There will also be a high deductible catastrophic plan that's available to people up to age 30. It will cover only limited benefits before the deductible is met.
Q: When a consumer enrolls in a marketplace plan is it for a year of coverage or longer? Can an insurer drop a consumer?
A: As long as you keep up with your insurance premiums and don't lie on your application for insurance by claiming that you're younger than you really are, for example, your insurer can't drop you.
Generally, people will be able to enroll in or change plans once a year during the annual open enrollment period. This first year, open enrollment on the exchanges will run for six months, from Oct. 1 through March of next year. But in subsequent years the time period will be shorter, just a few months long.
There are certain circumstances when people will be able to change plans or add or drop someone from coverage outside the regular annual enrollment period. This could happen if you lose your job, for example, or get married, divorced or have a child.
Q: Will the premiums be more expensive than what is offered on the individual market? How about co-pays, are they comparable?
A: New individual and small-group plans offered both through the health insurance marketplaces and on the private market will all have to offer a package of 10 essential health benefits, including prescription drugs, emergency and hospital care, and maternity care, among other things. They will also have to meet the same standards for consumer cost sharing. So experts don't expect that premiums on or off the exchanges will be very different.
Here's how it will work. There will be four types of plans with different levels of consumer cost sharing. In a platinum plan, the insurer will pay 90 percent of covered medical expenses and the consumer will be responsible for 10 percent, on average. In a gold plan, the insurer will pay 80 percent and the consumer 20 percent. Silver plans will pay 70 percent and bronze plans 60 percent. Within each type of plan, insurers will generally have some flexibility to vary deductibles, copayments and coinsurance.
Even though premiums may be comparable on and off the exchanges, there's a key difference to keep in mind. Consumers who buy a health plan through the online marketplaces may be eligible for premium tax credits there that can substantially reduce the sticker price on their policy.
Q: Is everyone who qualifies treated the same in this new marketplace? Do younger people get lower rates and people with pre-existing conditions get higher rates?
A: Starting next year, no one can be charged higher rates for health insurance because they have pre-existing medical conditions. But there are a few other individual details that insurers can factor in when setting premiums, including age and tobacco use. The law allows premiums for older people to be up to three times higher than those of younger people. That may seem like a lot, but in plans currently sold on the individual market, the differential between the two is often much greater.
The law also allows insurers to charge smokers 50 percent higher premiums for coverage on the exchanges than non-smokers. Smokers do tend to have higher health care costs than non-smokers. Still, a handful of states have decided not to implement this surcharge. They figure that the higher premiums may make coverage unaffordable for some smokers, who typically have lower incomes in the first place. Besides, they say, evidence is scant that charging people more for health insurance actually encourages them quit smoking.
Q: Is there is basic package of benefits that each insurance company must offer if it is part of a marketplace?
A: To ensure that plans sold on the state-based marketplaces provide comprehensive coverage, every plan must cover 10 so-called essential health benefits. The required benefits include prescription drugs, emergency and hospital care, doctor visits, maternity and mental health services, rehabilitation and lab services, among others. In addition, recommended preventive services must be covered without any out-of-pocket costs to consumers.
If states have additional mandated benefits, for infertility treatment or autism, for example, those services will also generally be included in the plans offered through the state marketplaces.
Q: Who can get government subsidies to help pay for insurance obtained through a marketplace? How will that work?
A: There are two types of subsidies that will be available. People with incomes up to 400 percent of the federal poverty level--about $46,000 for an individual or $94,000 for a family of four--may be eligible for premium tax credits to reduce the price of a policy. Cost-sharing subsidies that reduce a plan's deductibles, copayments and total out-of-pocket costs will be available to people with incomes up to 250 percent of the poverty level, or about $29,000.
During the online application process, you'll be asked to provide information about your income, which will be fed into a centralized data hub to determine your eligibility for subsidies.
Subsidies will generally be sent directly to the insurer, and the amount you owe in premiums or cost-sharing will be reduced.
If your income increases during the year, notify the exchange promptly so that you can avoid having to pay any tax credit overpayments. On the other hand, if your income goes down you could be eligible for a bigger subsidy. Either way it's important to notify the exchange if your income changes.
Q: If I don't currently have coverage and I'm required to obtain it because of the individual mandate, how can an exchange help me?
A: Through the marketplace, you can easily compare health plans in your area. But probably the biggest advantage to using the state marketplace is that through it you can find out if you're eligible for subsidies that will help make any health plan you buy on the exchange more affordable. Subsidies will be available to people with incomes up to 400 percent of the federal poverty level, or about $46,000 for an individual. In addition, if you're low income you can also learn if you or your family members are eligible for Medicaid or the Children's Health Insurance Program through the marketplace. If it turns out that you can't find a plan that costs less that 8 percent of your income, the marketplace is where you can apply for an exemption from the individual mandate.
Topics: Aging, Delivery of Care
Two years ago Pathways to Housing helped a homeless Alicia O. find an apartment and get regular medical care, the first steps on her way to changing her circumstances, and improving her life.
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Q: When must a consumer enroll in an exchange in order to start getting insurance benefits in January, 2014?
A: The online marketplaces will open for business on Oct. 1. That's when people will be able to begin checking out the health plans that are available in their area and signing up. The open enrollment period will run through March of 2014. If you want coverage to begin on Jan. 1, though, you'll generally need to sign up by Dec. 15 of this year, although some states may allow you a little more time. Still, consumer advocates that I've spoken with say that it's probably not a good idea to put off applying for coverage until the last minute, because during this first year of operation the exchanges will probably be working out some kinks and the process may take longer than expected.
Q: How does someone qualify to enroll in a marketplace? Are the rules the same in every state?
A: Almost anyone can shop for health insurance through the online state marketplaces, sometimes called exchanges, that will open in October. The only real exception is immigrants who are in this country illegally. They can't buy coverage on the exchanges under any circumstances. That's true whether your state is running its own exchange or letting the federal government do so.
Even though practically anyone can shop for coverage on a state exchange, only certain people will qualify for subsidies to make coverage more affordable there. Subsidies will be available to people with incomes up to 400 percent of the federal poverty level. That's about $46,000 for one person or $94,000 for a family of four.
Subsidies will only be available to people who don't have good coverage available elsewhere. So if you're eligible for Medicare or Medicaid, you can't get subsidies on the exchanges. Likewise, if your employer offers good coverage you won't qualify for subsidies. Good coverage in this case means a plan that doesn't cost more than 9 1/2 percent of your income and pays at least 60 percent of your covered medical expenses. If your employer plan comes up short in either of those areas, you could qualify for subsidized coverage on an exchange.
Topics: Politics, Health Reform, Medicare, Health Costs
With the Congressional Budget Office projecting a reduced cost for a long-term "doc fix," Congress may seize the opportunity to end the annual adjustments to Medicare reimbursement rates. Mary Agnes Carey and CQ Roll Call's Emily Ethridge discuss.
>> Listen to their conversation here.
MARY AGNES CAREY: Welcome to Health on the Hill. I’m Mary Agnes Carey. Amid the partisan battles over the 2010 health care law known as Obamacare, lawmakers may be close to bipartisan consensus on another health care issue – overhauling how Medicare pays physicians. Three Capitol Hill committees are discussing how to replace the “Sustainable Growth Rate” – known as the SGR. For years, Congress has passed last-minute patches to the formula to prevent Medicare physician payment cuts. And while there isn’t a unified approach or agreement on how to finance a fix, many analysts say Congress appears closer than ever to replacing the SGR. With us to discuss the latest developments is Emily Ethridge, a health care reporter for CQ Roll Call. Hi Emily.
EMILY ETHRIDGE, CQ ROLL CALL: Hi Mary Agnes.
MARY AGNES CAREY: It’s great to have you here.
EMILY ETHRIDGE: Thanks for having me.
MARY AGNES CAREY: Sure. Give us a little bit of background on the Medicare SGR. When was it created, what was its purpose, and why are people talking about repealing it?
EMILY ETHRIDGE: So this was part of the 1997 Balanced Budget Act. If you go all the way back to then, and we really thought this was a formula that would keep the payment rates for Medicare physicians more in line with the overall growth of the economy. For a few years, it worked out pretty well. For the first five years, it seemed OK. It basically puts a limit on how much physician payments can grow.
Around 2002, things started to get bad. It started calling for cuts. Every year since 2002, it has called for more and more cuts. Drastic – now I think it’s about 25 percent cuts to Medicare physicians if we let this formula take place. However, Congress hasn’t let it actually take place in the past 10 years. They keep doing these short-term patches, which is what everyone knows as the “doc fix.” That makes it actually more expensive every time they don’t let the cuts happen, they give physicians instead this tiny little raise and that means that every year the formula calls for deeper and deeper cuts.
MARY AGNES CAREY: So, as we know, before the August break, the House Energy and Commerce Committee passed a bill to repeal and replace the SGR. How would that measure work and how would they pay for it?
EMILY ETHRIDGE: We don’t know how they’ll pay for it and that is the biggest sticking point right now. That is going to be the thing that really makes or breaks whether this bill happens. Because it’s a pretty big price tag. Only repealing the SGR – just taking away the SGR for 10 years – is about $140 billion. That’s doing that without doing anything else you might want to do. Any other kind of payment models, any other Medicare reforms you might want to try to make. So we’re looking at a pretty big price tag on this bill and right now we have no idea how they make up for that cost.
But the Energy and Commerce bill, it would get rid of the SGR which is a huge goal for everybody. Then we would have a little transition period of five years, where they would just set small payment updates for all Medicare physicians. Then after that, physicians would be able to move into these alternative payment models. The idea here is to get away from the “fee-for-service” Medicare that most stakeholders and health care economists really hate.
MARY AGNES CAREY: That’s traditional Medicare.
EMILY ETHRIDGE: That’s traditional Medicare, that’s what we have now, fee-for-service. You perform a service, Medicare pays the doctor. People say it encourages volume of services over really good quality care. So they would try to put in these new models, under the Energy and Commerce bill, to get away from that and start rewarding the quality of care. Or having better outcomes while saving money for Medicare overall.
MARY AGNES CAREY: And also, there are other committees. In the House, we have the Ways and Means Committee working on the issue. In the Senate, it’s the Finance Committee. Do we know enough now to tell how those approaches might be different from each other and from what Energy and Commerce has done?
EMILY ETHRIDGE: Everyone says Energy and Commerce has a pretty good base of a bill and they like it. However, those other committees don’t like it enough to say that we’re just going to take that up, maybe make a few tweaks here and there and send it along on its way, which would be the fastest option. They seem to each have more, bigger changes in mind. Everyone really wants to put their own stamp on this bill. So I feel like we’re going to get similar-looking bills but not the exact same bill from all three committees.
MARY AGNES CAREY: Now as we both know -- you and I have reported on this for years -- the SGR has been with us for a long time. What’s the reason for all this momentum right now, and is this Congress really going to act to make a change?
EMILY ETHRIDGE: As you said this is really the closest we’ve ever gotten to having the SGR go away. The Energy and Commerce Committee marking up a bill and approving it unanimously – 51 to 0 – so it’s bipartisan support to get rid of this – is farther than we’ve ever come in the history of the SGR. The reason that really put the momentum behind this is, yes, Congress has been working on this for a long time, but earlier this year we got a very favorable score from the CBO, that $140 billion I mentioned earlier. That’s the lowest score, the lowest price tag for getting rid of the SGR that we’ve ever seen, really, in the past, I’d say, five years. So everyone said basically it’s a fire sale on the SGR. Let’s go for it and strike while the iron’s hot. Get rid of this before CBO changes its mind.
MARY AGNES CAREY: While it’s only $140 billion in Washington language it still is a $140 billion. So what are the likely ways for financing? What are the options?
EMILY ETHRIDGE: Traditionally, when they do these small patches they take money out of Medicare somewhere else. They find other ways to cut provider payments elsewhere, maybe cut specialty doctors instead of physicians, or hospitals. They look to Medicare to try to move money from one pile to another. That could definitely happen here, although again $140 billion, plus more most likely, is a big ask. Republicans would love to cut that money from the health care law, from the overhaul, I don’t really think Democrats will be on board with that, but maybe if they could get some of it from it from the health care law, that might be part of a bigger compromise that could happen.
There’s also a lot of talk about tax reform -- tax code overhaul – in some of these committees right now, in Ways & Means and Finance. So it’s possible they might find some things in the tax code that produce savings, and they might just tack that on to pay for it instead.
MARY AGNES CAREY: Speaking of the health care law, we know the House Republicans voted several times to defund all or part of that measure. Are we going to see more of those votes this fall?
EMILY ETHRIDGE: I definitely expect to see more votes in the House on repealing or trying to de-fund the health care law. Right now you have a big group of Republicans who want to de-fund the law – stop it all together – and are willing to put some things at risk to get that to happen.
You don’t have House leadership on board with that yet, and we really haven’t reached a critical mass of those Republicans who want to de-fund the law yet. It’s about a third of the House Republican caucus. So it remains to be seen whether we actually will see that vote this month or possibly next month. But it’s something they’re really working on. And I think if they don’t get that de-fund vote, they’ll get some other repeal votes or delay votes just to keep everybody satisfied.
MARY AGNES CAREY: And I think you’re talking here in the sense of de-funding as part of the continuing resolution to fund the government, correct?
EMILY ETHRIDGE: Right. Exactly.
MARY AGNES CAREY: So if that one doesn’t occur, you may see some more of these rifle shots to de-fund pieces of the ACA.
EMILY ETHRIDGE: Especially when we have a debt ceiling fight again in October, this could certainly come up as part of that.
MARY AGNES CAREY: Thanks so much, Emily Ethridge of CQ Roll Call.
EMILY ETHRIDGE: You’re welcome, thank you.
This was produced by Kaiser Health News with support from The SCAN Foundation.
Topics: Politics, Health Reform
Republicans have made it their "holy grail, their number one priority" to deny millions of Americans health insurance coverage through the 2010 health care law, President Obama said Friday.
During a White House news conference, Obama also said that the American public would have a hard time understanding why Republicans would choose to shut down the federal government over funding for the health law. Some Republicans are pushing their congressional leaders to not agree to any legislation to fund the government beyond Sept. 30 if it includes any money for the health law’s implementation. Here is the complete video segment and transcript of the health-care related part of the news conference:
QUESTION, ED HENRY, FOX NEWS: I want to ask you about two important dates that are coming up. October 1st you've gotta implement your signature health care law. You recently decided on your own to delay a key part of that. And I wonder, if you pick and choose what parts of the law to implement, couldn't your successor down the road pick and choose whether they'll implement your law and keep it in place
PRESIDENT OBAMA: I didn't simply choose to delay this on my own. This was in consultation with businesses all across the country. Many of whom are supportive of the Affordable Care Act, but -- and who -- many of whom, by the way, are already providing health insurance to their employees but were concerned about the operational details of changing their H.R. operations if they've got a lot of employees, which could be costly for them, and them suggesting that there may be easier ways to do this.
Now, what's true, Ed, is that in a normal political environment, it would have been easier for me to simply call up the speaker and say, "You know what? This is a tweak that doesn't go to the essence of the law. It has to do with, for example, are we able to simplify the attestation of employers as to whether they're already providing health insurance or not. It looks like there may be some better ways to do this. Let's make a technical change to the law."
That would be the normal thing that I would prefer to do. But, we're not in a normal atmosphere around here when it comes to, quote/unquote, "Obamacare." We did have the executive authority to do so and we did so. But this doesn't go to the core of implementation.
Let me tell you what is the core of implementation. It's already taken place. As we speak right now, for the 85 percent of Americans who already have health insurance, they are benefiting from being able to keep their kid on their -- on their plan if their kid is 26 or younger. That's benefiting millions of young people around the country, which is why lack of insurance among young people has actually gone down. That's in large part attributable to the steps that we've taken.
You've got millions of people who've received rebates because part of the Affordable Care Act was to say that if an insurance company isn't spending 80 percent of your premium on your health care, you get some money back. And lo and behold, people have been getting their money back.
It means that folks who've been bumping up -- up with lifetime limits on their insurance that leaves them vulnerable, that doesn't exist. Seniors have been getting discounts on their prescription drugs. That's happening right now. Free preventive care, mammograms, contraception, that's happening right now.
I met a young man today on a bill-signing I was doing with the student loan bill who came up to me and said, "thank you." He couldn't have been more than 25, 26 years old -- "Thank you. I have cancer. Thanks to the Affordable Care Act, working with the California program, I was able to get health care and I'm now in remission." And so, right now, people are already benefiting.
Now, what happens on October 1st, in 53 days, is for the remaining 15 percent of the population that doesn't have health insurance, they're going to be able to go on a website or call up a call center and sign up for affordable quality health insurance at a significantly cheaper rate than what they can get right now on the individual market. And if even with lower premiums they still can't afford it, we're going to be able to provide them with a tax credit to help them buy it.
And between October 1st into March, there will be an open enrollment period in which millions of Americans for the first time are going to be able to get affordable health care.
Now, I think the really interesting question is why it is that my friends in the other party have made the idea of preventing these people from getting health care their holy grail, their number one priority. The one unifying principle in the Republican Party at the moment is making sure that 30 million people don't have health care. And presumably, repealing all those benefits I just mentioned -- kids staying on their parents' plan; seniors getting discounts on their prescription drugs, I guess a return to lifetime limits on insurance; people with preexisting conditions continuing to be blocked from being able to get health insurance.
That's hard to understand as an agenda that is going to strengthen our middle class. At least they used to say, "Well, we're going to replace it with something better." There's not even a pretense now that they're going to replace it with something better. The -- the notion is simply that those 30 million people, or the 150 million who are benefiting from the other aspects of affordable care, will be better off without it. That's their assertion, not backed by fact, not backed by any evidence. It's just become an ideological fixation.
Well, I tell you what, they're wrong about that. There is no doubt that in implementing the Affordable Care Act, a program with this significance, there are going to be some glitches. No doubt about it. There are going to be things where we say, "You know what? We should have thought of that earlier"; or "this would work a little bit better"; or "this needs an adjustment."
That was true of Social Security. That was true of Medicare. That was true of the children's health insurance program, that was true on prescription drug program Part D that was rolled out by a Republican president and supported by Republicans who are still in the House of Representatives. That's true, by the way, of a car company rolling out a new car. It's true of Apple rolling out the new iPad.
So, you know, you will be able to whenever you want during the course of the next six months and probably the next year find occasions where you say, ah-ha, you know what, that could have been done a little better or that thing -- they're kind of making an administrative change. That's not how it was originally thought this thing was going to work.
Yes. Exactly. Because our goal is to actually deliver high quality health care for people and to reform the system so costs start going down and people start getting a better bang for the buck. I make no apologies for that.
And let me just make one last point about this.
The idea that you would shut down the government unless you prevent 30 million people from getting health care is a bad idea. What you should be thinking about is how can we advance and improve ways for middle class families to have some security so that if they work hard, they can get ahead and their kids can get ahead.
QUESTION, JESSICA YELLIN, CNN: Thank you, Mr. President.
And following on what you just said, Republicans in the House might give that you choice soon to either allow the government to shut down or see Obamacare defunded. Would you choose to let the government shut down to ensure that Obamacare remains funded?
OBAMA: Well, you know, I'm not going to engage in hypotheticals.
I can tell you that the American people would have difficulty standing why we would weaken our economy, shut down our government, shut down vital services, have people who are not getting paid, who then can't go to restaurants or shop for clothes or all the other things that we're doing here, because Republicans have determined that they don't want to see these folks get health care.
Again, they used to say they had a replacement. That never actually arrived, right?
I've been hearing about this whole replace thing for two years. Now I just doesn't hear about it, because basically they don't have an agenda to provide health insurance to people at affordable rates.
And the idea that you would shut down the government at a time when the recovery is getting some traction, where we're growing, although not as fast as we need to, where the housing market is recovering, although not as fast as we would like, that we would precipitate another crisis here in Washington that no economist thinks is a good idea.
I'm assuming that they will not take that path.
I have confidence that common sense in the end will prevail.
QUESTION: And if they do, sir? Do you have to make that choice?
OBAMA: We'll see what happens. We got a couple months.
QUESTION: When is the last time you spoke to Speaker Boehner about the budget?
OBAMA: Fairly recently. Yeah, probably right before they left.
KHN's Mary Agnes Carey talks with Politico Pro's Paige Winfield Cunningham about the latest Republican effort to delay or repeal Obamacare provisions, including putting off a mandate on individuals to carry health insurance.
MARY AGNES CAREY: Welcome to Health on the Hill, I'm Mary Agnes Carey. The Obama administration's decision to postpone, by one year, a requirement that companies with 50 or more workers offer health insurance or pay a fine has brought heavy criticism from Republicans on Capitol Hill.
Today, members of the House Ways & Means health subcommittee examined the administration's decision to postpone the health law's employer mandate. With us to discuss the hearing is Page Winfield Cunningham of Politico Pro. Thanks for joining us.
PAIGE WINFIELD CUNNINGHAM: I'm glad to be here.
MARY AGNES CAREY: Paige, you and I have covered a lot of these hearings on the Affordable Care Act, which is also known as the ACA. And today, I heard a lot of what I've heard at some of those other hearings: Democrats defending the law, Republicans attacking it. What was new?
PAIGE WINFIELD CUNNINGHAM: You’re absolutely right. We've heard the same arguments over and over again from Republicans. But what I think was new today was that they do have a new piece of ammunition to throw at the same target. And that is now that the administration is giving employers another year to comply with the law, Republicans are trying to make the case that this is really unfair to individuals and families who are also going to be faced with this mandate. And they're saying, "If you’re going to treat one person, give one party the special treatment, you really should apply it across the board to everyone."
But, they're really trying to use that argument to aim at the same thing, and that is the overall health care law. So you're hearing a lot of the same arguments that the law is not ready; that the administration is saying it will be, but it won’t; other parts of the law have already been repealed; the exchanges aren't all rolling out as the administration thought with some states refusing to run them themselves. So they're trying to feed all of this into that broader argument that the health care law is just fundamentally flawed.
MARY AGNES CAREY: What did Democrats say about this delay in the employer mandate? Do they support it?
PAIGE WINFIELD CUNNINGHAM: Absolutely. They're trying to make the case that the administration is just listening to the business community, which has been very vocal over the last year, saying that they need more time, they need more details about the regulations, that that they’re not going to be ready on Jan. 1.
So Democrats are saying: "Hey, the administration is doing its best job to roll out a really big, complicated law. They’re just listening and being attentive." You also saw ranking member Jim McDermott (D-Wash.) talk a lot about how this is really just one small piece of the law. It’s not really going to affect that many people. There was a small portion of folks that were expected to get employer-sponsored coverage next year. But in the broad scheme of things, this is just one piece of the puzzle.
So they’re saying Republicans are really blowing this up too much.
MARY AGNES CAREY: This isn't the only hearing on this subject. Kevin Brady (R-Texas), who heads the Ways & Means health subcommittee, said they're going to have another hearing next week. They'll have a witness from Treasury there to discuss the delay. We know there are other Hill committees with hearings on the horizon.
How might those be different? What might we learn in addition at those hearings?
PAIGE WINFIELD CUNNINGHAM: I think Republicans are really trying to capitalize on this opportunity before the August recess, so you’re right, they’re rolling out a lot of hearings. We might even see one come out of the Education & the Workforce Committee, which has a little bit of jurisdiction.
I think they’re trying to really drill down and find out why the administration made this decision, what was going on behind the scenes. But mostly they really, I think, want to call the administration out and make them publicly talk about this and really put them on the hot seat and force them to answer questions about this. There had been some suggestions by Republicans that the administration didn’t have the legal authority to do this. So that’s probably going to be part of the discussions, as well.
MARY AGNES CAREY: You mentioned this is now in the political arena, as well. House Speaker John Boehner has promised additional votes on the ACA. Tell us about those.
PAIGE WINFIELD CUNNINGHAM: It is going to be a really busy month. There could be three votes this month before they leave for recess. One would be to also delay the mandate for individuals and families. That could possibly be paired with another bill that would basically do what the administration has already done, which is delay the employer mandate. The Republicans want to force Democrats to vote on that [employer provision], and then hold a vote on individuals and families, to kind of call them out that way. And then a third vote would be on a bill sponsored by Congressman Tom Price. That would be to basically ban IRS from doing anything to implement the law.
So we could see three votes on that coming down the pipeline very soon.
MARY AGNES CAREY: Who does this bring political leverage to in the midterms? The Republicans? The Democrats? Both?
PAIGE WINFIELD CUNNINGHAM: It's a little hard to say at this point. Probably Republicans, because they’ve been trying to make a case all along that this law was not going to be ready in time, and here’s a piece of evidence they can point to. I guess the thing working in favor for the Democrats is: The business community had been very, very vocal about wanting a delay and wanting some changes. This decision is allowing the administration to say: Hey, we’re listening to you, we’re attentive to what the stakeholders are saying.
So we’ll see how it plays out. But Republicans are going to keep this in the forefront as much as they can.
MARY AGNES CAREY: Thank you so much, Paige Winfield Cunningham.
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