Topics: Insuring Your Health, Insurance, Marketplace

How Does The Health Law Affect Premiums For Smokers?

Michelle Andrews answers a question from a reader about how the health law affects insurance for smokers and programs may help them quit.

QUESTION: The health law will soon allow some insurers to charge up to 50 percent higher premiums for smokers. How will the insurer know who is a smoker? As an HR rep, how will I be able to convince our employees to take this seriously? -- Ann

ANDREWS: The provisions that allow insurers to charge smokers higher premiums take effect in January and apply to health plans sold on the individual and small group markets that aren't grandfathered under the law. The insurer may well rely on people to self-report their tobacco use, asking them, for example, if they've used tobacco regularly in the past six months. You're apparently concerned that people won't disclose that they're smokers, and some may not. But it's important to remember that research shows that most smokers want to quit, and under the health law people won't be penalized as long as they're trying to do so, even if they don't succeed. If a company has a wellness program that offers a tobacco cessation program and if smokers participate in it, they're not going to have to pay the higher rate. Participation is enough, workers don't have to actually succeed at quitting, which often takes several tries. So that may encourage people to 'fess up to their smoking habit.

Topics: Politics, Health Reform

Obama: Health Law 'Working The Way It's Supposed To' (Video)

In California Friday, President Barack Obama praised the health law benefits already in place and talked about the state's health insurance marketplace. He also placed a special emphasis on touting the law to the state's Latino population.

Here's a transcript of his remarks:

OBAMA: These leaders from California's government, the California Endowment, and major Spanish-language media outlets have joined together to help implement the Affordable Care Act here in California and to educate folks about how to sign up and shop for quality affordable plans. And their efforts have already shown some excellent results in the biggest insurance market in the country.

There are two main things that Americans need to know when it comes to the Affordable Care Act and what it means for you. First of all, if you're one of the nearly 85 percent of Americans who already have insurance, either through Medicare or Medicaid or your employer, you don't have to do a thing. You've just got a wide array of new benefits, better protections, and stronger cost controls that you didn't have before, and that will over time improve the quality of the insurance that you've got, benefits like free preventive care, checkups, flu shots, mammograms, and contraception.

You are now going to be able to get those things through your insurance where they previously were not -- didn't have to be provided, protections like allowing people up to the age of 26 to stay on their parents' health care plans, which has already helped 6 million Americans, including 6 million young Latino Americans.

Cost controls like requiring insurance companies to spend at least 80 percent of the money that you pay in premiums in your actual health care costs, as opposed to administrative costs or CEO pay, not overhead, but that money has to be spent on you. And if they don't meet that target, they actually have to reimburse you. So in California, we're already getting reports that insurers are giving rebates to consumers and small-business owners to the tune of $45 million this year.

So already we're seeing millions of dollars of rebates sent back to consumers by insurance companies as a consequence of this law. All of that is happening because of the Affordable Care Act. All of this is in place right now already for 85 percent of Americans who have health insurance.

By the way, all of this is what the Republican Party has now voted 37 times to repeal, at least in the House of Representatives. And my suggestion to them has been, let's stop re-fighting the old battles and start working with people like the leaders who are on stage here today to make this law work the way it's supposed to.

We're focused on moving forward and making sure that this law works for middle-class families, and that brings me to the second thing that people need to know about the Affordable Care Act. If you're one of nearly 6 million Californians or 10 million -- tens of millions of Americans who don't currently have health insurance, you'll soon be able to buy quality, affordable care just like everybody else. And here's how.

States like California are setting up new online marketplaces, where beginning on October 1st of this year, you can comparison shop an array of private health insurance plans side-by-side, just like you were going online to compare cars or airline tickets, and that means insurance companies will actually have to compete with each other for your business. And that means new choices.

See, right now, most states don't have a lot of competition. In nearly every state, more than half of all consumers are covered by only two insurers, so there's no incentive to provide you a lot of choices or to keep costs down. The Affordable Care Act changes that.

Beginning next year, once these marketplaces are open, most states will offer new private insurance choices that don't exist today. And based on early reports, about 9 in 10 Americans expected to enroll in these marketplaces live in states where they'll be able to choose between five or more different insurers.

So, for example, here in California, 33 insurers applied to join the marketplace. Covered California then selected 13 based on access, quality and affordability, four of which are brand new to your individual market. So what's happening is, through the Affordable Care Act, we're creating these marketplaces with more competition, more choice. And so the question is, what happens to cost?

Now, a lot of the opponents of the Affordable Care Act said -- you know, they had all kinds of "sky is falling," doom-and-gloom predictions that not only would the law fail, but what we'd also see is costs would skyrocket for everybody. Well, it turns out we're actually seeing that -- in the states that have committed themselves to implementing this law correctly, we're seeing some good news. Competition and choice are pushing down costs in the individual market, just like the law was designed to do.

The 13 insurance companies that were chosen by Covered California have unveiled premiums that were lower than anybody expected. And those who can't afford to buy private insurance will get help reducing their out-of-pocket premiums even further with the largest health care tax cut for working families and small businesses in our history. So about 2.6 million Californians -- nearly half of whom are Latinos -- will qualify for tax credits that will in some cases lower their premiums a significant amount.

Now, none of this is a surprise. This is the way that the law was designed to work. But since everybody's been saying how it's not going to happen, I think it's important for us to recognize and acknowledge, this is working the way it's supposed to.

We've seen similar good news, by the way, not just here in California, but in Oregon and Washington. In states that are working hard to implement this law properly, we're seeing it work for people, for middle-class families, for consumers.

Now, that's not to say that everything's going to go perfectly right away. When you're implementing a program this large, there will be some glitches. There are going to be some hiccups. But no matter what, every single consumer will be covered by the new benefits and protections under this law permanently.

So the bottom line is, you know, you can listen to a bunch of political talk out there, negative ads and fear-mongering geared towards the next election, or alternatively you can actually look what's happening in states like California right now. And the fact of the matter is, through these exchanges, not only are the 85 percent of people who already have health insurance getting better protections and receiving rebates and being able to keep their kids on their health insurance until they're 26, and getting free preventive care, but if you don't have health insurance, and you're trying to get it through the individual market, and it's too expensive or it's too restricted, you now have these marketplaces where they're going to offer you a better deal because of choice and competition.

And if even at those lower rates and better insurance that you're getting through these marketplaces you still can't afford it, you're going to be getting tax cuts and tax credits through the Affordable Care Act that will help you afford it. And that's how we're going to make sure that millions of people who don't currently have health insurance or are getting a really bad deal on their health insurance are finally going to get it.

But -- and here's my final point. To take advantage of these marketplaces, folks are going to need to sign up. So you can find out how to sign up at healthcare.gov, healthcare.gov. Or here in California, you can sign up at coveredca.com, coveredca.com.

Because quality care is not something that should be a privilege. It should be a right. In the greatest country on Earth, we've got to make sure that every single person that needs health care can get it. And we've got to make sure that we do it in the most efficient way possible.

One last point I'm going to make on this, because there are a lot of people who currently get health insurance through their employers, the 85 percent who are already out there, and they may be saying, well, if -- if this law's so great, why is it that my premiums still went up?

Well, part of what's happening across the country is in some cases, for example, employers may be shifting more costs through higher premiums or higher deductibles or higher co-pays, and so there may still be folks who are out there feeling increased costs not because of the Affordable Care Act, but because those costs are being passed on to workers. Or insurance companies, in some cases, even with these laws in place are still jacking up prices unnecessarily.

So this doesn't solve the whole problem, but it moves us in the right direction. It's also the reason why we have to keep on implementing changes in how our health care system works to continually drive better efficiency, higher quality, lower cost. We're starting to see that. Health care cost inflation has gone up at the lowest rate over the last three years that we've seen in many, many years. So we're making progress in actually reducing overall health care costs while improving quality, but we're going to have to continue to push on that front, as well. That's also part of what we're doing in the Affordable Care Act. All right?

But the main message I want for Californians and people all across the country, starting on October 1st, if you're in the individual market, you can get a better deal. If you're a small business that's providing health insurance to your employees, you can get a better deal through these exchanges. You've got to sign up, healthcare.gov, or here in California, coveredca.com. All right? So, thank you very much.

Topics: Insuring Your Health, Insurance, Marketplace

Can I Stop My Health Reimbursement Account From Being Drained?

Michelle Andrews answers a question from a reader about who pays first when there is coverage from two insurance plans.

QUESTION: I have a high deductible health insurance policy and my wife is in an HMO. I use the HMO for medical services and use my HRA to pay long-term care insurance premiums and dental expenses. This year, the HMO began sending bills to my insurer instead, so now money is being drained from my HRA account. Can this be stopped? -- Peter

ANDREWS: It probably can't be stopped. It sounds as if what you're describing has to do with so-called "coordination of benefits" rules. These are rules that spell out which insurer is responsible for paying first and which pays second in situations where someone is covered under two different policies, in this case yours and your wife's. Benefits experts I asked said that in general if you're covered as an employee under your employer's plan that policy is going to be responsible for paying your claims first. Your wife's plan, under which you're covered as a dependent, would generally pay second, perhaps, for example, covering benefits that your primary insurer doesn't cover.

Topics: Insuring Your Health, Insurance, Hospitals, Health Costs, Delivery of Care

Can My Insurer Deny Coverage For Care At An Out-Of-Network Hospital?

Michelle Andrews answers a reader question about emergency room and out-of-network hospital cost changes under the health law.

QUESTION: I went to an out-of-network hospital but my insurance case worker told me I would be covered since I was admitted through the ER. Can my insurer now deny coverage? -- Michael

ANDREWS: It's unlikely that your insurer would deny coverage altogether if you were admitted to an out-of-network hospital. But it might refuse to cover your hospital care at in-network rates. Consumers now have better protection for emergency care they receive at out-of-network facilities. Under the health care overhaul, in most instances insurers can't charge higher copayments or coinsurance if people wind up getting emergency care at an out-of-network hospital. However, if you're admitted to the hospital following a visit to an out-of-network ER, you're no longer protected from higher cost-sharing. The insurer can charge you for your hospital care based on your plan's regular out-of-network coverage rules.

Topics: Insuring Your Health, Insurance

My Insurer Says It Paid Too Much. Do I Have To Reimburse Them?

Michelle Andrews answers a reader question about having to repay an insurer that says it reimbursed too much after the patient received care from an out-of-network provider.

QUESTION: I recently received a bill from my insurer related to a pre-approved operation three years earlier with an out-of-network provider. The insurer says it mistakenly reimbursed me too much and I owe $9,100. Can they do this? – Lisa.

ANDREWS: They may be able to ask you to repay that money. These situations can come up for different reasons, but often you’ll see it in instances when someone receives care from an out-of-network providers, as you did. The insurer may send the check – or checks – directly to you, the health plan member, leaving it to you to pay the provider who delivered the care. According to insurance industry experts I spoke with, from the insurer’s perspective, that approach is sensible since they don’t have a contractual relationship with the out-of-network provider. Unfortunately that may mean that you – the health plan member – are responsible for repaying any amounts that the insurer sent you and later determines that it overpaid, even if you sent that money directly to the provider, perhaps without even cashing the check. If you want that money back to repay the insurer, you may have to go looking for it from the provider.

Topics: Insuring Your Health, Insurance

Under-26 Coverage: Does It Matter If My Child Just Got Out Of Jail?

Michelle Andrews answers a reader question about keeping your children on your health plan until they turn 26, even if they were recently released from jail.

QUESTION: My son was taken off our policy at age 18 because he was in jail. Now, he is at home and our insurer says he cannot be added to our coverage because it was a "one-time deal." Under the ACA, is this true? -- Linda

MICHELLE ANDREWS: No, it's not true. Your son can be added to your policy again and remain on it until he turns 26, unless he has an offer of health insurance coverage through his own job. In that case, he might have to take that coverage instead. But in most cases, young adult children can stay on their parents' plan. Generally, health plans provide an open enrollment period every year when people can change their coverage or add dependents to their plan, and you should be able to do the same.

Topics: Health Reform, Politics

Obama: 'The Law Is Here To Stay'

President Barack Obama gave a speech Friday on the health law, and he emphasized his administration's commitment to moving forward with a full rollout of all the law's provisions. Here is the transcript of the president's remarks released by the White House:

Thank you. Thank you so much, everybody, and welcome to the White House. I want to thank Carol for the wonderful introduction.

And let me just start off with a public service announcement to dads, partners, kids of America -- Sunday is Mother's Day. You should not forget. You can't go wrong with flowers, a homemade card, giving some mom -- giving mom some relief, some quiet time. That is appreciated.

So it's a day when we put moms first. And I still remember one time I said to Michelle -- this is back when we had just gotten married and I think Malia had just been born, and we were fussing around Mother's Day, and I said, but you know, how come we do so much stuff on Mother's Day? She says, because every other day is Man's Day. So this is like one day. And there was, as usual, profound insight in Michelle's remarks because moms so often put themselves last; so often they put everything else before themselves.

And that's particularly true when it comes to things like health care. Moms take care of us. ... Sick kids, aging parents, grumpy husbands. And I know there are lots of moms out there who often go without the care that they need, or the checkups they know they should get, because they're worrying that co-pay has to go to gas, or groceries, or the new soccer uniform instead. Or worse, they know the unfairness of being charged more for their health care just because they're a woman, or the stress of trying to manage a family budget when health care costs are impinging on it, or trying to insure a sick child only to be told "no" over and over again.

So we decided that needed to change. In a country as wealthy as this one, there was no reason why a family's security should be determined by the chance of an illness or an accident. We decided to do something about it.

Thanks to the women in this room and people all across the country, we worked really hard -- and it's now been more than three years since Congress passed the Affordable Care Act and I signed it into law. It's been nearly a year since the Supreme Court upheld the law under the Constitution. And, by the way, six months ago, the American people went to the polls and decided to keep going in this direction. So the law is here to stay.

And those of us who believe that every American deserves access to quality, affordable health care have an obligation to now make sure that full implementation moves forward the way it needs to.

Basically, there are two main things that the American people need to know about this law and what it means. First, if you're one of the nearly 85 percent of Americans who already have health insurance -- whether it's through your employer, or Medicare or Medicaid -- you don't have to do a thing. This law already provides you with a wide array of new benefits, tough new consumer protections, stronger cost control measures than existed before the law passed. And those things are already in place -- you're benefiting from, you just may not know it. Making sure that insurers can't take advantage of you. Making sure that your child can stay on your health insurance until they're 27 years old. So a lot of those provisions are already in place providing help and assistance to people all across the country.

Now, second, if you're one of the tens of millions who don't have health insurance, beginning this fall, you'll finally be able to compare and buy quality, affordable private plans that work for you. So that's what you need to know. If you've already got health insurance, this has just enhanced it. And if you don't, you're going to be able to get it.

For three years now, this law has provided real and tangible benefits to millions of Americans. Women in particular now have more control over their own care than ever before. And I'm pleased to be joined today by many women who wrote in to tell us what the Affordable Care Act means to them.

Carol Metcalf told us, "My oldest child is 22, recent college grad, a traumatic brain injury survivor with a rare genetic lung disease. Without the Affordable Care Act, he would have been removed from our family health insurance policy this year. And his health is excellent, but the cost of maintenance is overwhelming. And given his history, he would be virtually uninsurable under the old set of 'rules.' Instead of contemplating law school, all of his resources would have been channeled into somehow, somewhere, finding health insurance." That's what Carol wrote.

So Carol and her son Justin are why the Affordable Care Act lets young people stay on their parent's plan until they turn 26. And today, as she put it, "now Justin's future is governed by what he wants to achieve, not what health insurance mandates." And, by the way, Justin is here -- a fine-looking young man right here. Sunday is Mother's Day. Just wanted to make sure you remembered that.

Alycia is the mother of Avey, who is a beautiful, sweet, 3-year-old girl who also happens to have leukemia. Imagine what that's like for a parent. While you’re just figuring out how to take care of a baby, you've got to figure out how you're going to pay for expensive treatment that could save your baby's life.

Any parent knows that there is nothing we won't do to take care of our kids. And it's nice to have somebody getting your back. And that's why the Affordable Care Act made it illegal for bad actors in the insurance industry to discriminate against kids like Avey. And today, Avey is doing just great. She was here just a second ago, where is she? There's Avey -- hey, sweetie! So Alycia wrote in -- she said, "The health care law is about people like me. It's AlyciaCare."

And because of AlyciaCare -- the Affordable Care Act -– insurance companies can no longer impose lifetime limits on the amount of care you receive, or drop your coverage if you get sick, or discriminate against children with preexisting conditions. And women now have access to free preventive care like checkups, and mammograms, and cancer screenings, so you can catch preventable illness on the front end. And that provision has already helped more than 70 million Americans with private insurance. That's already happening. A lot of people don't know it, but you've got those protections.

Because of the Affordable Care Act, young adults under the age of 26, as we talked about, are able to stay on their parent's health insurance plan -- and that's already helping more than 6 million young adults.

Because of the Affordable Care Act, seniors on Medicare receive free checkups and preventive care with no co-pay or deductible, and get a discount on their prescription drugs. That has already saved over 6 million seniors more than $700 each. That's already been happening. Seniors may not know that they've been getting $600 discounts, but it's there.

Because of the Affordable Care Act, insurers now have to justify double-digit rate increases publicly, for everybody to see. And most states have new authority thanks to incentives under this law to reject unjustifiable rate increases. Insurers are now required to spend at least 80 percent of the money you pay in premiums on actual health care -– not on profits, not on overhead, but on you. And if they fail to meet that target, they actually have to reimburse you -- either with a rebate or lower premiums. Millions of Americans discovered this last year -- they opened an envelope from their insurance company that wasn't a bill, it was a check. That's already happened. A lot of people don't know it, but that's what the Affordable Care Act is all about.

Beginning this week, as part of the law's price transparency tools, we made public the prices that different hospitals charge you for most common services, so you can see if you're getting what you pay for. And soon, bad actors in the insurance industry will never again be able to discriminate against you just because you've gotten sick in the past. They can't discriminate against you because you've got a preexisting condition. And, by the way, they can't charge you more just for being a woman. Pregnancy will no longer be considered a preexisting condition.

And finally, beginning this fall, if you're one of the millions of Americans who don't have health insurance, you’ll finally have the chance to buy quality, affordable care just like everybody else.

So here’s how this is going to work. We're setting up a new online marketplace where, beginning October 1st, you can go online, or talk to organizations in every state that are going to have this set up, and you can then comparison shop an array of private health insurance plans. You can look at them side-by-side, just like you'd go online and compare cars. And because you'll now be part of a new pool of millions of other Americans, part of this exchange, insurance companies will actually want to compete for your business the same way they compete for the business of a big company with a lot of employees.

So once these marketplaces are up and running, no one can be turned away from private insurance plans. Period. If you're sick, you’ll finally have the same chance to buy quality, affordable health care as everybody else. If you can’t afford to buy private insurance, if it's still too expensive -- even though you're getting much better prices through these exchanges than you would in the individual market, going out there by yourself, or if you work for just a small company that doesn't have a lot of leverage with insurance companies you're going to have a better deal through these exchanges -- but if you still can't afford it, then you're going to get help reducing your out-of-pocket premiums with the largest health care tax cut for working families and small businesses in our history.

So what does all this mean? It means that if you lose your job, or you change your job, or you start that new business, you'll still be able to purchase quality, affordable care that's yours -- and you'll have the security and peace of mind that comes with it. If you're a young person expecting to try many different jobs and careers until you find one that suits you, you'll be able to buy insurance that goes with you, travels with you, that gives you the freedom to pursue whatever you want without the fear that illness or accident somehow derails your dreams.

So there's a lot that this law is already doing for Americans with insurance, and there is a lot more that is going to happen for folks who don't have insurance. But we've still got a lot of work to do in the coming months to make sure more Americans can buy affordable coverage. And with something as personal as health care, I realize there are people who are anxious, people who are nervous, making sure that we get this done right.

So I'm here to tell you, I am 110 percent committed to getting it done right. It's not an easy undertaking, but if it were easy, it would have already been done a long time ago. Undoubtedly, there will be some mistakes and hiccups as the thing gets started up, but we're learning already from them. For example, when the prototype of the application to join the marketplace came in at 21 pages -- the initial first cut at it -- we said, you know what, we can do better than that. It's now three pages long. Three pages. By the way, the industry standard is actually about 17 pages. So three pages is good. That's a lot shorter than the application you generally have to fill out now for private insurance.

But this is going to be a lot of work. And obviously, there is still a lot of political bickering over this law. The same folks who fought tooth and nail four years ago and tried to make political hay out of Obamacare, they're still telling tall tales about its impact. Some small businesses are being told their costs are going to go up, even though they're exempted from the law or they actually stand to benefit from it. And whenever insurance premiums go up, you're being told it's because of Obamacare -- even though there's no evidence that that's the case. So right now there are a whole bunch of folks out there, their insurance company decided to jack up rates, and they're automatically assuming, well, somehow the law had something to do with it. No, that had to do with a decision the insurance company made. In some cases, employers may be shifting more costs onto employees because they think that will help their bottom line. It's convenient to somehow say, well, it must be the new law. It's not the case.

So precisely because there’s been so much misinformation, sometimes people may not have a sense of what the law actually does. And that misinformation will continue -– at least through the next Election Day.

But what all the people on this stage understand is this is too important for political games. Most moms and dads don't think about politics when their kid gets sick. They're thinking about doing whatever it takes to make sure that child is well. This is an issue of personal security. This is personal to Carol and Alycia and anybody who's ever known the injustice and anxiety of a broken health care system. That's what this is about. That's why we fought so hard to make this happen. And that's why we're determined to get it done right.

And we're going to need everybody out there to make sure --get the right information. Don't just read a blog -- or some commentary from some pundit that has a political agenda. Make sure you know what the actual facts are, because you stand to benefit if you're not already benefiting from this thing. Don't let people confuse you. Don't let them run the okiedoke on you. Don't be bamboozled.

Now, there's one more person I want to mention here today -– somebody who I’ve spoken of several times over the past few years. When I first received a letter from Natoma Canfield, she was a self-employed cancer survivor from Ohio; she'd always done the responsible thing by buying her own insurance on the private market, even though it was very expensive.

A few years ago, her insurance company charged her over $6,000 in premiums, paid for only $900 worth of care, told her they'd jack up her rates another 40 percent anyway -- even though she'd been cancer-free for more than a decade. Despite her desire to keep her health insurance -- despite her fears that she would get sick again -- she finally just had to surrender her coverage. Couldn't afford it. Hung her fortunes on chance. And just a few weeks later, she fell ill, and was diagnosed with leukemia. Just days before health care reform became a reality.

And I kept Natoma's story with me as we fought to pass this law, and I hung her letter on one of my walls in the Oval Office. And while she couldn't be there the day I signed the Affordable Care Act into law, Natoma is here today. And because of this law -- here's Natoma right here. Give her a big round of applause. Because of this law, there are millions of other Americans -- moms and dads, and daughters and sons -- who no longer have to hang their fortunes on chance.

Because we are not going to inflict that hardship on the American people again. The United States of America does not sentence its people to suffering just because they don't make enough to buy insurance on the private market. Just because their work doesn't provide health insurance. Just because they fall sick or suffer an accident -- that could happen to anybody. And regular access to a doctor or medicine or preventive care -- that's not some earned privilege, it is a right.

So I understand the politics of this stuff sometimes, but there are times when I just want people to step back and say, are you really prepared to say that 30 million Americans out there shouldn't have health insurance? Are you really prepared to say that's not a worthy goal? Because of politics?

That's why we're going to keep fighting with everything we've got to secure that right, to make sure that every American gets the care that they need when they need it at a price that they can afford. That's what our families deserve. That's what the vast majority of Americans believe in. That's what we're going to make sure that we deliver. And we're going to do it with your help.

Thank you very much, everybody. God bless you. Thank you.

Topics: Politics, Health Reform

What's Next In The Senate: In The Coming Weeks And After 2014

Jackie Judd talks with KHN's Mary Agnes Carey about what's next for the stalled confirmation of Marilyn Tavenner, and who will fill the void in health policy when three senior Senate Democrats retire in 2014.

>> Listen to their conversation here.

JACKIE JUDD: Good day, this is Health on the Hill. I'm Jackie Judd. A stalled confirmation and retirements among senior Senate Democrats involved in health care policy top our conversation today with Mary Agnes Carey of Kaiser Health News. Welcome, as always. Well, for a minute there, it looked like Marilyn Tavenner, who has been heading the [Centers for Medicare & Medicaid Services] for sixteen months now, was finally going to get a full Senate vote. And then it didn’t happen because of [Iowa Sen.] Tom Harkin. What does he want?

MARY AGNES CAREY: Tom Harkin, who championed funding for prevention in the health law, is upset that the administration is going into that fund to take money out to implement the health care law. And the reason they’re doing that is the administration has asked for more funding from Congress, but Republicans on Capitol Hill don’t want to grant that request. So as we know the health law's exchanges have to be up and running this fall, the navigators who are supposed to help people understand how to navigate the exchanges need to be up and running, and so the administration has got to go into existing funding, including the prevention fund.

JACKIE JUDD: But Harkin believes that there are other sources of funding.

MARY AGNES CAREY: He does.

JACKIE JUDD: And has he made any headway with the White House?

MARY AGNES CAREY: Not that we know of yet. I’m sure that they're having conversations back and forth, and one thing that intrigues me – to your point – is Tom Harkin is an appropriator. He's on the Senate Appropriations Committee, he runs the subcommittee that oversees HHS, and when Tom Harkin says: I think there are other places they can get the money, I have a feeling that they’ll listen to that.

JACKIE JUDD: Let's presume that Marilyn Tavenner eventually will be confirmed by the full Senate. What is the practical impact of her being the head of the agency as opposed to the acting?

MARY AGNES CAREY: I think when you are confirmed as the administrator of an agency, it gives you a little more gravitas to express your vision of where you think it needs to go and to get that vision implemented. Now, to be sure, the agency hasn't had a confirmed administrator since 2006, and they have been working very hard – employees there – to implement Medicare and Medicaid and so on. But I think that it’s that extra oomph – to use that word – if you are confirmed as administrator.

JACKIE JUDD: Mary Agnes, Tom Harkin is one of three [Senate] Democrats who has announced their retirement. One of three involved in health care issues – Jay Rockefeller, West Virginia is another; Max Baucus, of course, who is currently chair of the Finance Committee. It’s going to be a real policy drain. Again, an impact question. What is the impact when three people like that – three lawmakers very committed in their own ways to health care policy – what impact may it have?

MARY AGNES CAREY:  I think looking ahead, before the 2014 elections all of these senators had made it very clear that they’re going to use their power to implement the health law as they see fit. We've just talked about Tom Harkin. We can’t forget about Max Baucus, head of the Senate Finance Committee, who just a week or so ago grilled Secretary Kathleen Sebelius, who heads HHS, saying that he saw a "train wreck" coming on implementation of the health law.

And Jay Rockefeller is another health care champion on Medicare, Medicaid and the ACA, so I think leading up to the election, while people know they're not going to be around after 2014, they also know they’ll be wielding the power they have before that point.

JACKIE JUDD:  But will they suffer from being lame ducks?

MARY AGNES CAREY:  To some extent, one can make that argument.

For example, Max Baucus has been in negotiations with Dave Camp of the House Ways & Means Committee about a possible overhaul of the tax code. And there are thoughts that that may weaken Sen. Baucus' ability to negotiate that -- or if they chose to look at the entitlement structure.

But, again, 2014 is a bit away, that election, and I do think the lame duck thing does figure in, but they will work as hard as they can this year to try to avoid that.

JACKIE JUDD:  Presuming that Democrats maintain control of the Senate after the 2014 elections, who is waiting in the wings? Who will be the new Tom Harkin? New Rockefeller? The New Baucus?

MARY AGNES CAREY:  There are many, many Democrats who are very strong on health care. But here are some people that I have watched that I think are very interesting to follow:

When you talk about health care and Democrats, you've got to talk about Ron Wyden of Oregon. He is behind Sen. Baucus, behind Sen. Rockefeller, the next ranking Democrat to take over Finance. He may or may not be the Finance chairman, but he's got a long tenure on that committee.  He started his career with the Gray Panthers. He knows a lot about Medicare and Medicaid. He has reached across the aisle. He sponsored something called the Healthy Americans Act with Bob Bennett, the former Republican senator of Utah, that would de-link insurance from employment.

He worked with Paul Ryan, the House Budget chairman, Republican in the House, on an early version of premium support – not the one that's currently in the House budget, but an earlier version of that. So he's one to keep your eye on.

I think Ben Cardin, who is on the Finance Committee, a former House Ways & Means Committee member, is very interesting. He asks a lot of very interesting questions on Medicare and Medicaid. And Sherrod Brown is another Democrat, formerly in the House. He's a former member of the Health, Education, Labor & Pensions Committee in the Senate. He's now on Finance. And for 18 years, Sherrod Brown would not take the health insurance that's offered to members of Congress and their staffs, because he felt it was not fair for him to have that advantage over his constituents. But since the passage of the ACA, he has enrolled in that insurance. But I think he'll be one to watch on health care, as well.  

JACKIE JUDD:  Thanks so much, as always, Mary Agnes Carey of Kaiser Health News.

Topics: Insuring Your Health, Insurance

My Child Moved Away, Can I Keep Him On My Insurance?

Michelle Andrews answers a reader question about keeping your children on your health plan until they turn 26, even if they move away.

ANDREWS: You're right. Even if an adult child no longer lives nearby, in most instances the health reform law allows him to stay on your health plan until he turns 26. As a practical matter, though, he may run into difficulties. Even though he has insurance he may have a hard time finding providers that are in your health plan's network if he lives out of state. In that case he -- or you -- could wind up paying a lot more for him to use out-of-network doctors. Some adult children sidestep the problem by waiting to go to the doctor until they come back home to visit mom and dad. Maybe that will work for your son. But children who have chronic health conditions may have a tougher time delaying medical care. In those cases, you may want to explore other options, like state-based plans that guarantee coverage for people with pre-existing conditions.

Topics: Insuring Your Health, Insurance, Marketplace

Is My Retiree Insurance Coverage Subject To The Health Law?

Michelle Andrews answers a reader's question about whether retiree health plans must comply with new rules under the ACA.

ANDREWS: The new company may be correct. Health insurance plans that cover only retirees generally don't have to abide by the provisions of the Affordable Care Act. I've seen this issue come up with older parents who have adult children. Under the health care overhaul, health plans have to allow adult children to remain on their parents' health insurance plans until the reach age 26 in most instances. But if the parents are retired and covered by a retiree-only plan, those health reform provisions don't apply. Experts I asked say the rationale may have been a concern by those drafting the law that if they made retiree-only plans subject to it, employers would discontinue coverage. If the plan you're in contains both active and retired workers, I'm told it would be subject to the law. It's worth double-checking with the company to make sure that's not the case.

Topics: Politics, Medicare, Medicaid

Tavenner Fields Questions on Leaks, Premium Costs, Future Of Medicare

House Majority Leader Eric Cantor, R-Va., set the tone for a very-supportive Senate Finance Committee hearing on Marilyn Tavenner's nomination to head the Centers for Medicare & Medicaid Services. But Tavenner, who is acting administrator, did get questions about leaks to the press from Sen. Charles Grassley, R-Iowa, about a recent insurance actuary report on insurance premium costs, from Sen. Mike Enzi, R-Wyo., and from Sen. Max Baucus, D-Mont., about moving away from fee-for-service Medicare. Here are excerpts of the hearing.

Topics: Insuring Your Health, Insurance, Health Costs

Can They Do That? Rules For Pricing Spousal Coverage

Michelle Andrews answers a reader's question about employers who charge a different premium to cover a spouse who has coverage available through his or her own job.

Topics: Politics, Health Reform

At Health Law Anniversary, Even Bigger Changes Loom

A roundtable of reporters weighs in on what’s changed since the ACA became law three years ago for consumers, businesses, state governments, and what's next for expanding Medicaid and launching exchanges.

A transcript follows.

JACKIE JUDD: Good day, I’m Jackie Judd and this is the “ACA at 3.”

PRESIDENT OBAMA (Voiceover): We have now just enshrined, as soon as I signed this bill, the core principle that everybody should have some basic security when it comes to their health.

JACKIE JUDD: What’s changed since that day for consumers, businesses, state governments, with the coming expansion of Medicaid and the creation of exchanges? What challenges lie ahead?

We answer those questions with journalists who’ve covered every angle of the Affordable Care Act. Joining me: Mary Agnes Carey, of Kaiser Health News, Jay Hancock, also of KHN, Sam Baker, of The Hill, and Christine Vestal, of Stateline. Welcome to you all.

Sam, exchanges – or marketplaces, as the administration now likes to call them – it’s a mixed bag at the moment: Some states are doing it on their own, some looking to the federal government for support, and then there’s a partnership. Give us a broader picture.

SAM BAKER: Exchanges are arguably the cornerstone of the health care law. It’s the biggest structural new thing that was created. And it was envisioned initially as something the states would very much take the lead on. The assumption was each state would want to control its own marketplace or its own exchange. That hasn’t really proven true. I think the federal government is going to be totally running exchanges in 26 states. Of the minority who are working in some capacity with the federal government, a few are running their exchanges entirely on their own, but there’s also some interest in this partnership model – as what HHS calls it – where the work is divided between the state and the federal government.

JACKIE JUDD: In the states where the federal government alone will be running the exchanges, is it going to be a one-size-fits-all or will the states have input?

SAM BAKER: The states won’t have much input. It’s sort of an interesting question to put to HHS about whether it’s a one-size-fits-all, because on the one hand they say, “Once you build one exchange, it’s easy to upscale that to 26 exchanges.” But they’re also in this pitch to get states to do more and more. They’re also trying to emphasize that each one would be customized to each state, and you’d have different carriers in different states, so a little bit of a balance between the two.

JACKIE JUDD: Enrollment begins in October. They actually start running in January. Are most states at the point – and the federal government as well – at the point at which they will be ready to go in October?

SAM BAKER: The federal government insists that they are. Anytime you ask, it’s “We will be ready. We will be ready.” On the other hand, they did just request and didn’t get some extra money from Congress to help stand up and run exchanges, which would seem to be a sign that there’s not enough money to do that in what they have now, but they say they’ll make it work.

JACKIE JUDD: The other significant expansion of that access, of course, is going to happen through Medicaid when income requirements change. Chris, you’ve spent a lot of time covering that story. How many states are in? How many are out? How many are on the fence?

CHRISTINE VESTAL: Twenty-five governors have said yes, either through their budgets or declarations they’ve made. Eight of those are Republicans. Fourteen have said no, and the rest are undeclared. But that’s not the end of it. Now, state legislatures have to approve the governor’s [declarations], and that’s not necessarily going to happen in all of the states. There are – in the eight Republican-led states – five of them [where] it’s going to be quite a battle.  And if not all states say yes, there will be big disparities in 2014. They can decide later, the following year, and a lot of people predict that’s what may happen.

JACKIE JUDD:  Are some governors trying to cut special deals? You and I just saw a story out of Maine where the governor of Maine is saying: We will expand Medicaid if you, the federal government, pick up the entire bill for the next decade.

CHRISTINE VESTAL:  That’s a one-of-a-kind, as far as I know, but there other deals. Governors early on asked for a lot of things and got some nos and got some yeses.

One of the more interesting deals right now was forged by Arkansas and Ohio, with the administration. It hasn’t come out on paper yet, but apparently the administration is saying they can use Medicaid money from the federal government to purchase private insurance on the exchanges for this new population, which will be adults with incomes up to 138 percent of poverty.

So that's privatizing, using more of a market approach, which may appeal to the Republican legislators that aren’t in favor of the expansion.

JACKIE JUDD:  There have been some very tangible results of the ACA. Children -- young adults up to the age of 26 -- can stay on their parent’s policy. Some preventive services are now free. When it comes to Medicare beneficiaries, over the past three years, Mary Agnes, what kind of changes have these individuals seen?

MARY AGNES CAREY:  There have been some new services added to Medicare. For example, an annual wellness visit that wasn’t there before, some more cancer screenings – and all these preventive services now don’t have copays or deductibles.

For example, in 2012 you had 34 million Medicare beneficiaries avail themselves of these new benefits. There’s also have been some changes in the Medicare prescription drug arena: A closing of this “doughnut hole,” that gap in coverage where seniors are on their own. And about six million beneficiaries have saved almost $6 billion on their prescription drugs as a part of the health law.

JACKIE JUDD:  The secretary of health and human services, Kathleen Sebelius, was touting all of the results of the preventive services piece, in recognition of the third anniversary.

The other big piece of Medicare is the payment structure, linking pay to performance. You attended a Senate Finance Committee hearing just yesterday. What kind of results do we have this early on?

MARY AGNES CAREY:  We don’t have results this early on, and that was a problem for some of the Senate Finance Committee members. Richard Gilfillan, who runs the Center for Medicare and Medicaid Innovation -- they’re overseeing the accountable care organizations, bundled payments, the readmissions policies – was really urging the senators and, frankly, every member of Congress: “Please be patient. These take time. Some are going to work. Some are not going to work. And as soon as we have results, good or bad, we’re going to share them with you.”

JACKIE JUDD:  Jay, you have a very big swath of this story. You cover the marketplace, meaning insurance companies, employers, etc.

Going back to the discussion we had with Sam and exchanges, what kind of indications are you seeing from the insurance companies about whether they’re going to jump into the exchanges? And what kind of challenges are there with that?

JAY HANCOCK:  It’s still a little bit early.

JACKIE JUDD:  Really? It’s March. They started in October.

JAY HANCOCK:  Oh, absolutely. It’s March. They started in October, yes.

Part of it is due to the fact that the exchanges are still rolling out. Some of the insurers are saying: We can’t make decisions until we see what the exchanges look like. Some of the rules are still being written by HHS and the Treasury Department. 

What we do know is that the insurers that have spoken out publicly about this – the private insurers – have said, the CEO of United Health, for example, has said: Don’t assume we’re going to offer a plan in every market where there’s an exchange. Even United Health, that has a nationwide footprint, their CEO has said: We will not do it unless it makes sense for us economically, for our shareholders, and unless we think this market’s going to stick around and be there for a while. Which points out the uncertainty of the whole thing -- these are critical. The insurance companies are the vehicles. This whole plan was written to be a filtered through the private insurers for the most part, for people under 65. And if they’re not there in force, that’s a big question mark.

JACKIE JUDD:  And so do you think that they would be on the sidelines for a year or two to see how these exchanges work? And are there any carrots that the administration could provide the insurers -- or the states even -- to encourage the insurance companies to get in?

JAY HANCOCK:  In some cases, if you’re not there in the first year, there’s a penalty. And I don’t think anybody’s going to sit this out entirely. I suspect we’ll see everybody with a foot in the water somewhere, and they’ll forget we’re going to have two national insurance plans which don’t get talked about very often.

But in addition to all the state based plans, there are going to be a non-profit and for-profit national plan in every state that will have benefits and compete with whoever the local offerings are there. The thinking is that the blues organizations will also be quite active in this, and be pretty interested in being in the markets in the first place.

JACKIE JUDD:  Part of the issue of growing the exchanges, as well as expanding Medicaid, is how do you reach people who are eligible and let them know what’s available? The Kaiser Family Foundation just released another survey yesterday that showed the very people who could most be impacted by the ACA understand it the least. Two-thirds of the people who are uninsured, and about two-thirds of people families who are under $40,000, don’t really understand how it will impact them. So Chris and Sam, you could each take this one: What kind of enrollment efforts are going to be made, or going to have to be made to pull people in?

CHRISTINE VESTAL:  One thing that’s going to happen is that [with] Medicaid, states don’t have a choice. They have to make it easier to enroll in Medicaid. So the application process will be easier, which should mean that more people are successful once they find out about it. And this lack of outreach has been a problem in Medicaid already. There are thousands, maybe millions, of people who already qualify for Medicaid and haven’t either heard about it, don’t want to apply, or tried to apply and couldn’t pull together all the paperwork. But I think most of the marketing is going to be through the exchanges.

SAM BAKER:  The exchanges could be sort of a heavier lift, you know. The administration has said it’s going to have a pretty significant outreach education campaign over the summer. There’s an independent group that’s formed called Enroll America, which is an offspring of some advocacy groups, that’s also going to try to help raise [awareness].

JACKIE JUDD:  That helped elect the president.

SAM BAKER:  Right, [it] now will take ostensibly a more objective role in just making sure that the law works. But that poll that you mentioned really did indicate the challenge of explaining something that is pretty complicated. You know there was a big political fuss, last week or two weeks ago, about a draft of the application to enroll.

JACKIE JUDD:  15 pages or something like that.

SAM BAKER:  Right. It had all sorts of information that most people wouldn’t know about their employer plan and almost asking them to figure out for themselves whether they were eligible for subsidies – which is a really complicated determination even for the IRS. So, there are some real hurdles there.

JAY HANCOCK: One of the underrated enrollment forces here is going to be the providers. Nobody has a bigger incentive to make sure that you have coverage than the hospital or the doctor who’s taking care of you.  I suspect they may also be part of the mix.

JACKIE JUDD:  Have you seen evidence or heard evidence of that, Jay?

JAY HANCOCK:  Yeah. The hospital –one of the for-profit hospital companies, Tenet Healthcare, told investors a couple weeks ago that they’re gearing up in a very disciplined fashion to make it easy for their patients to explore their options on the exchanges if they don’t have coverage when they’re at the hospital.

MARY AGNES CAREY:  And they’re also going to have a series of navigators, right? These are individuals that are kind of boots on the ground to explain to people: You do qualify for Medicaid; this is how you navigate that exchange form. But to your point, it’s also in the best interest of the providers to get these folks enrolled, because otherwise they’re uncompensated care. 

JACKIE JUDD:  And some states are being pretty aggressive in terms of simplifying the process. I know in one state – I believe it’s Utah or possibly Michigan – you can sit down in front of a computer with a navigator and find out instantly if you going to be eligible for Medicaid. If so, you would then get the benefits.

Jay, you also cover employers, small business. You talked, before we started taping, about something called avoidance and coping strategies. What do you mean by that?

JAY HANCOCK:  Well, we should call it avoidance, coping, and compliance strategies, because many employers will end up signing employees up for insurance.

To back track a little bit, the Affordable Care Act requires employers with at least fifty workers to offer affordable coverage to their full-time workers. After that headline, there’s a lot of moving parts underneath. What’s a full-time worker? One of the things employers are looking at now is: Okay. If I had sixty employees, and I’m not offering coverage, is there some way that I can go under that fifty line? Employers are talking about hiring part-timers. So that reduces their total employee count. It’s part of their formula – it’s part-timers plus full-timers and then you take an average of their hours.

They’re talking about outsourcing. There’s a lot of talk about partnering with temp staffing agencies like Manpower and Kelly Services, because if all my frontline employers are working for Manpower, they aren’t technically my employees. That might put me under the fifty mark. That might be a way to increase my part-time workers.

There’s a lot of discussion going on about this in the employer community. There are also small employers saying: Look. We have a health plan for our employees. They like it. It helps us retain good workers, and we think it will be good for you as well.

JACKIE JUDD:  Are you talking about the self-insurance there?

JAY HANCOCK:  Self-insurance is another wrinkle in this. That wasn’t what I was referring to, but self-insurance is a whole other thing that I think is going to get more attention this year because of federal court cases that go back way beyond what we want to talk about. If you’re self-insured as an employer, which is to say if you fund most of your employees’ health cost through your own finances, you are exempt from several measures under the Affordable Care Act including the insurance premium taxes that come with this, including the pricing rules that says you basically can’t charge a lot less for young healthy employees and you can’t charge a lot more for older folks with pre-existing conditions.

And, there’s the worry now that even smaller employers are going to be switching to self-insurance, which they can do by buying reinsurance policies, which is something else we don’t need to get into, but the bottom line is it’s another potential out.

I had a story last week in which one of the people I talked to, who is no fan of the Affordable Care Act, sees this as a loophole that could undermine small business exchanges in the states, because if employers see an opportunity to self-insure their young, healthy workers, that may leave older sicker folks in the exchanges and drive up premiums and make it less affordable.

JACKIE JUDD: Others who were not fans of the Affordable Care Act three or four years ago and to this day, of course, warn that for some small businesses the impact of the law would mean they would be out of business. Is there evidence of that?

JAY HANCOCK: “Out-of-business” would be the extreme case. I haven’t heard too many people saying this is going to make me close up my doors and go home. However, whether or not this is effecting job creation is something that’s being talked about a lot these days. The Federal Reserve, which does a periodic survey of business conditions and is not a partisan organization, reported a few weeks ago that businesses were telling their surveyors that they were holding off a little bit on hiring. They wanted to see how all of these uncertainties about the exchanges that we’re talking about were going to play out. They wanted to understand the law more. And until that happens they may hold off -- if they are talking about expanding that would put them over the 50 mark -- that may keep them from doing some hiring as well.

At the same time, however, you should point out that the economy is doing pretty well. We had a great jobs report last month, and we’re just going have to see how things turn out between now and next year.

JACKIE JUDD: Sam, in recent days backers of the ACA, friends of the White House, have begun to express some concern that premiums will be higher than had been anticipated and had been promised when the law was being debated. What are you hearing?

SAM BAKER: There are sort of two sides to that question. In one sense and for some plans, premiums will be higher basically by design. The law does away with certain plans that are referred to as mini-meds that are very cheap but also the coverage is usually pretty skimpy -- it will carry high out-of-pocket costs or have a cap on how much it will play out. So people who were insured with one of those plans will now have a more comprehensive plan that will be more expensive, but that’s sort of a value determination that the law makes that this is something that should happen.

There is also the question – insurers refer to it as premium shock, the sticker shock once so many new regulations kick in at the same time, which would be the beginning of next year that you have new limits on how much you can charge based on age, based on health status, pre-existing conditions. Younger people are probably the people who would bear the brunt of any increases, because they are generally cheap to insure now, and by bringing sicker people into the system and by providing guarantees of coverage to them you might be shifting some costs onto the younger workers.

JAY HANCOCK: What insurers will also tell you, generally off the record, is that they’re insuring what by definition is sort of terra incognita, an unknown territory. These are people who by definition have lacked coverage in the past, and insurers will say: Look, we don’t know the health histories of these populations. We don’t know the claims histories, and when push comes to shove that may cause us to decrease our risk by raising our premiums rather than taking the chance that there might be higher than expected claims histories with some of these newly insured folks.

JACKIE JUDD: And one part of the unknown territory, Chris, is this question of with so many more people becoming insured, will there be enough doctors, especially primary doctors, to take care of them?

CHRISTINE VESTAL: That’s a big question, especially for Medicaid, because Medicaid pays lower rates. Primary care doctors got a raise this year, paid for by the federal government. It will be paid for one more year. After that it will be up to states to continue the pay raise or not.

But one of the things states are doing as they look at this expansion, they’re saying this program isn’t working anyway. A lot of them feel that it is inefficient and that doctors’ time is not spent well. So one of the ways, rather than adding new doctors, which you can’t do overnight, states are looking at having doctors work in teams so that they’re not the only ones spending time with patients.

JACKIE JUDD:  Nurse practitioners?

CHRISTINE VESTAL: Nurse practitioners, also expanding their scope of practice so that they can work at the top of their skill level. That’s another initiative that’s going forward.

JACKIE JUDD:  We can’t really have a conversation about the ACA without talking about the politics, which continue in force.

Just last week Congressman Paul Ryan introduced a budget on the House side, in which he called for the repeal of the ACA. As time goes on that seems so, kindly put, less and less likely. So what is the goal of Republicans in the coming year as the ACA becomes more ingrained in our system?

MARY AGNES CAREY: We’ve talked about a lot of these provisions that kick in in 2014, so that’s a year away. So if you’re going to make the case against the ACA, if you have any hope of stopping implementation, which as you noted, they really don’t because the president is a Democrat and the Democrats run the Senate, they still want to make their case.

Paul Ryan was asked a question during the budget rollout at a news conference like: You didn’t win the election. Republicans didn’t get the White House. You didn’t get the Senate. Why do you persist? And this and a variety of other provisions that don’t seem likely to go forward, and Paul Ryan said: Look, these are our principles.

They don’t like the ACA. They want to defund it. The House voted something like 33 times last year to defund either part or all of it. And you see those amendments coming up again on the budget resolution, on the continuing resolution. And while they’re not successful, Republicans tell me: This gives us the chance to make our case on why we think the ACA is terrible.

Even yesterday in the Senate Finance hearing I attended, Orrin Hatch, the ranking member, a Republican from Utah, said he sees a train wreck in 2014; things will be a disaster and then people will finally understand the Republicans’ concern about the ACA.

But one note on the Paul Ryan plan. We’ve got to remember that while he would repeal the ACA, he would keep all those savings, all those cuts to providers as part of his budget. So, there was some questioning on that as well.

JACKIE JUDD: I would like to end our conversation on predicting, as your lawmaker did, a year from now, what things may look like in each of your areas, Medicaid, exchanges, marketplace and Medicare. A year from now, what will you be looking for to report on whether things have been successful or whether they are not working as people had hoped. Chris?

CHRISTINE VESTAL: Well with Medicaid, first of all, it will be interesting to see how many states actually do take the very good offer from the federal government and expand Medicaid. And then, among those that do, how well is it working?  How much are these new people using their Medicaid card?  Are they having to wait too long to get appointments?  And how are the hospitals doing? That’s going to be a big question, especially in states that don’t expand.  Because they [the hospitals] will not get a subsidy that they’ve been getting for uninsured patients.  So there may be a push in those states to go ahead and make the move.

SAM BAKER: On exchanges, I think the top-flying concern is just how many people enroll which will sort of be how you judge the law’s political success. They said it would cover about 30 million people. How close do you get to that number?  And how many young people enroll?  Because that will have a pretty big impact on premiums and on whether the goal of bringing young people into the system to offset other projections is fulfilled.

JAY HANCOCK:  I think we will have functioning exchanges in every state, but I suspect there will be hiccups.  A lot of people are concerned that 2014 will be the acid test of the Affordable Care Act, and I would suggest that that’s probably not the right test.  A lot of people compare this to Medicare Part D, which was passed in the last decade.  I think that’s a good benchmark.  The lesson is, in terms of how long it takes to work things out.   And when Medicare Part D was adding prescription drug benefits to Medicare, Mary Agnes, how many years did that take to get smoothed out and have everyone understand it and insurers participating and so forth?

MARY AGNES CAREY:  It took a while, but the thing to remember about this is that [program] was adding drug coverage to a population that understood the Medicare program. What’s really different here is you’re bringing in millions of people who may not know anything about how to get health insurance, so that’s a further complication in implementation.

JAY HANCOCK:  That’s true. What the Act’s defenders say is don’t judge us on 2014.  And I think that’s probably fair.

JACKIE JUDD: As a final word, I’ll let you judge 2014, Mary Agnes.

MARY AGNES CAREY:  I think we have to see do these measures to link the payment for care to the quality delivered, do they really work?  You’ve already see wrinkles in implementation of the ACOs – the accountable care organizations, bundled payments, the readmissions policy that providers are pushing back on.  We have a series of payment changes to Medicare Advantage and to hospitals and other providers.  And now we have sequestration – this additional 2 percent cut that’s in place [for Medicare providers]. Providers have a way of putting political pressure on to reverse cuts. And what will happen with those in 2014 and the years ahead?

JACKIE JUDD: Thank you to each and every one of you for bringing your expertise to the table. I appreciate it.  Thank you for watching The ACA At Three.  I’m Jackie Judd.

This video was produced by Kaiser Health News with support from The SCAN Foundation.

Topics: Insuring Your Health, Medicare, Delivery of Care

Q&A: I Had To Return To The Hospital; Will They Be Penalized?

Consumer columnist Michelle Andrews answers a reader question about what triggers Medicare's penalties for hospitals who readmit patients too frequently.

Topics: Delivery of Care

Osteopath Aims Approach At Filling Primary Care Gap

Dr. Valerie Goodman, an osteopathic doctor, explains osteopathic medicine and how it influences how she delivers patient-centered care at her practice in rural Centreville, Md.

Video Produced by Shefali S. Kulkarni

Related Story: Osteopathic Physicians: An Answer To Rural Health Care Needs?

Topics: Insurance, Health Reform

Q&A: How Does Marriage Affect Health Coverage For The Young?

Consumer columnist Michelle Andrews answers a reader question about under-26 insurance coverage for newlyweds.

Topics: Medicare, Politics, Health Costs

Obama: 'I've Offered Sensible Reforms To Medicare'

In a statement to the press Tuesday, the president emphasized the need to reduce the cost of health care in the U.S.

A transcript follows:

PRESIDENT BARACK OBAMA: For all of the drama and disagreements we've had over the past few years, Democrats and Republicans have still been able to come together and cut the deficit by more than $2.5 trillion through a mix of spending cuts and higher rates on taxes for the wealthy.

A balanced approach has achieved more than $2.5 trillion in deficit reduction. That's more than halfway towards the $4 trillion in deficit reduction that economists and elected officials from both parties believe is required to stabilize our debt. So we've made progress. And I still believe that we can finish the job with a balanced mix of spending cuts and more tax reform.

The proposals that I put forward during the fiscal cliff negotiations in discussions with Speaker Boehner and others are still very much on the table.

I just want to repeat: The deals that I put forward -- the balanced approach of spending cuts, and entitlement reform and tax reform that I put forward -- are still on the table. I've offered sensible reforms to Medicare and other entitlements, and my health care proposals achieved the same amount of savings by the beginning of the next decade as the reforms that have been proposed by the bipartisan Bowles-Simpson fiscal commission.

...

These reforms would reduce our government's bills by reducing the cost of health care, not shifting all those costs onto middle-class seniors or the working poor or children with disabilities, but, nevertheless, achieving the kinds of savings that we're looking for.

But, in order to achieve the full $4 trillion in deficit reductions that is the stated goal of economists and our elected leaders, these modest reforms in our social insurance programs have to go hand-in-hand with a process of tax reform, so that the wealthiest individuals and corporations can't take advantage of loopholes and deductions that aren't available to most Americans.

Topics: Insurance, Women's Health, Health Reform

Q&A: Contraception Coverage Under The Health Law

Consumer columnist Michelle Andrews answers a reader's question about the health law’s provision on no-cost birth control.

>> Watch Andrews answer more of your health insurance questions.

>> Read "Insuring Your Health" - a collection of Andrews' consumer columns

Q. Is it true that all birth control should now be provided free of cost to all women? I thought this provision of the ACA had gone into effect months ago. I know some women who are still being charged. -- Marilyn

A. Under the health care overhaul's expansion of preventive coverage, women may be eligible to receive free contraceptive services, including all FDA-approved methods of birth control. But there are some exceptions: The provisions apply to new private health plans; plans that have "grandfathered" status under the law don't have to comply with the new rules. As time passes, more plans are losing their "grandfathered" status, but a significant proportion are still exempt from the requirement.  In addition, health plans sponsored by certain nonprofit religious employers like churches, synagogues and other houses of worship -- are completely exempt from the requirement. And some religiously affiliated institutions like faith-based hospitals and universities aren't subject to the new rules until August 2013. By that time, the Department of Health and Human Services will have come up with new rules to enable employees of those institutions to have access to free contraception through their insurers.