NPR's Julie Rovner joins KHN's Mary Agnes Carey talk about developments on the Hill. This week: With the one-year anniversary of the health law this week, proponents of the measure point to many of its provisions, such as insuring adult children up to age 26 on a parent's policy or tax credits to help small businesses afford coverage, as signs that the law is succeeding. But opponents of the law say many of its provisions, such as the Medicaid expansion or a requirement that most individuals have health insurance or pay a fine, will weaken public support.
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JACKIE JUDD: Good day. I am Jackie Judd. This is Health on the Hill. A year ago this week President Obama signed into law the most ambitious social program since Medicare was created 45 years earlier. Mr. Obama described enactment of the health care reform law as a reflection of a country prepared to make the hard, necessary and right decisions.
JACKIE JUDD: Well, it has been a rough ride since that glittering signing ceremony. Here to review the past year and look ahead are Mary Agnes Carey, Senior Correspondent for Kaiser Health News and National Public Radio's Julie Rovner. Thank you both. You are among the best health policy reporters out there so the best to analyze what the past year has looked like.
Of the parts of the law that have been implemented so far, what's working as the Democrats had envisioned it would? First you, Mary Agnes.
MARY AGNES CAREY: They can point to all the adult children up to age 26 who have now stayed on the health insurance plan, that was one of the items; no rescissions, no canceling of health insurance once you get sick. Something like more than 80 million people with health insurance plans can get preventive care with no deductibles or copayments.
There's help for small business tax credits, to help them cover insurance. They're looking at all these different elements of the laws. They try to sell it to the public to say this is why many of you support health reform, this is why we need the health law.
JACKIE JUDD: Julie, what's on your list?
JULIE ROVNER: I think they've also had these new benefits for seniors on Medicare. Seniors, of course, were very skeptical of this law, as well they might have been - seniors are pretty happy with their Medicare and what they were hearing during the debate is all this money was going to be taken away. So seniors who have had this big doughnut hole in their drug benefit - meaning they got benefits and then the benefits dropped out before they picked up again - last year if they fell into the doughnut hole they got a $250 check, this year they're getting a 50 percent discount on name brand drugs if they reach that doughnut hole. They're also getting preventive care with again, with no deductible like many people. And they're also getting an annual wellness physical, something that they haven't gotten in Medicare before.
So again, new benefits for seniors to let them know that this has got something for them, so there's something to bring seniors along, who I might point out are still a little bit doubtful about the merits of this law for them.
JACKIE JUDD: And what in your view is working less well than what the Democrats had envisioned? The first one that comes to mind for me is the high-risk insurance pool; 375,000 people had been predicted to join this, about 12,000 as of February have. Mary Agnes?
MARY AGNES CAREY: Part of it is the fact that you have to be uninsured for six months and you have to have been rejected for coverage due to an illness. Part of it is the cost, part of it is awareness. A lot of people still don't know that those pools are out there and the Department of Health and Human Services are trying to build awareness for the pools, as are states, and they've also lowered the premiums of the pools that the federal government is running. States can run their own or they can have the federal government run it. That one has not turned out as they had hoped.
JULIE ROVNER: You know, I think some of this is almost being too cautious. They were afraid, in fact, a lot of Governors didn't sign up to run these pools themselves because they were afraid these pools would be swamped. So they put all of these sort of obstacles, if you will, to prevent the pools from being swamped by too many people. And I think what's happened has been the opposite, that they've had not enough people.
But I don't think a lot of people said well that it's a recognition that the need wasn't there. I don't think it's a recognition that the need's not there, there's still plenty of people who don't have insurance, I hear from them every day - who need insurance who, have pre-existing conditions - it's just that they may be put up too many gates to get into these particular pools.
JACKIE JUDD: And what about the provision that lifted pre-existing conditions, a ban on pre-existing conditions for children?
JULIE ROVNER: This was something that they were going to do right away. They can't really lift the ban on pre-existing conditions for adults until they get this requirement that everybody have insurance. So those two things happened at the same time in 2014, but they thought that they could do it for children. That would be something right away that people would see. Well, you had the problem that you would have had if you just lifted the ban on pre-existing conditions for adults, which is that insurers said, hey, if you let everybody in, that we're going to have what they call the death spiral - that we're going to be swamped with all of these kids with pre-existing conditions and they're going to come in only when they get sick. And you had plans in a lot of states say we're going to stop writing policies for child only coverage. And so they had to do some quick adjustments in some states. And I think in most states they managed to get most of those insurers who threatened to not write coverage anymore back to writing coverage. But it was quite a bit of tap dancing there when a lot of those insurers said if you pull this ban on pre-existing conditions exclusions for children and let children basically come in when they get sick.
JACKIE JUDD: And in the past year the administration itself has signaled that it wants to make some adjustments to this law - one is 1099, the other is the CLASS Act.
MARY AGNES CAREY: Right, exactly. The 1099 debate is still ongoing on Capitol Hill. And of course, this is a requirement that if you purchase more than $600 in goods or services from any vendor, you've got to issue the 1099. It's been viewed as onerous for small business. Republicans hate it, Democrats hate it, the President would like to get rid of it.
But in Congress, the House has one approach to finance that, the Senate has another, they’re trying to find a compromise on that. As far as the CLASS Act, again, this is a long-term care support act. The thought is perhaps they need to make changes to make it financially sustainable. Republicans had gone after the CLASS act on this very fact and Secretary Sebelius has come out and said maybe we need to adjust premiums; we need to make some other adjustments to make sure it is financially sustainable for the long run.
JACKIE JUDD: Okay. Now it's time to get the crystal ball out for a moment. There had been so many challenges to this law, both in the courts, in the states, on Capitol Hill, efforts to defund, Governors agitating for greater flexibility. In the coming year, Julie, what do you see as the most serious challenge to this law remaining as it is now?
JULIE ROVNER: I still think that one of the really serious challenges to this law is the fact that the public still doesn't understand what it does. Every month we see the tracking poll from the Kaiser Foundation and it says that just this last one still says a year in the most pervasive emotion associated with this law is confusion. And I think opponents are still really playing on this confusion, and it's very hard to build support for something that people don't understand. And that is the strategy of the opponents, to really go after - they know they don't have the votes in congress, because it's still obviously Democratic Senate, Democratic President - so they're going to try and go after it, as you mentioned, from every possible avenue that they can in the courts, in the Congress, even though they know they can't win, in the states.
And you've got a public that still doesn't know what to believe in terms of what this law does and still really misunderstands fundamentally a lot of the things that this law does and doesn't do. For example, you’ve still got a lot of people who think there are death panels in this law. We just discovered from this current tracking poll that much of the public believe that they're going to have to drop their employer provided health insurance in 2014 —
JACKIE JUDD: To meet the individual mandate?
JULIE ROVNER: Right and buy your own. That's not the case if your employer offers health insurance that meets the mandate, you don't have to go out and buy your own. So there's still a lot of fundamental misunderstanding of what the law actually requires.
JACKIE JUDD: Mary Agnes, you get the final word.
MARY AGNES CAREY: I think Julie nailed it as usual. Americans all over the country are going to look at this and think, what's in it for me, what's in it for my family. And if the administration and backers of the bill can win that case, then it will have great public appeal. But Republicans, of course, on The Hill, are going to keep hammering away at the things they disliked about the law and who wins in the court of public opinion.
JACKIE JUDD: And unlike the past year, when there were certain markers that the administration could point to and say to the elderly, you're getting a $250 check, in the coming 12, 18, even 24 months, there aren't those kind of markers coming up.
MARY AGNES CAREY: No. You'll have new implementing regulations, of course, but the main show now is 2014 - that's when the Medicaid expansion begins, that's when the health insurance exchanges are launched and the subsidies are launched. So while there isn't anything new, if you will, coming online, proponents of the law will go back to all the things we talked about just a few moments ago to sell this law to the public.
JACKIE JUDD: Okay. Thank you both so much, I appreciate it.
MARY AGNES CAREY: Sure.