- Email: [email protected]
Second round of enrolment begins under Affordable Care Act
World Report
Second round of enrolment begins under Affordable Care Act Ahead of the next phase of enrolment for insurance plans, Republicans vowed to target the health law following their election win. Susan Jaffe, Washington correspondent, reports. Federal health officials promise that last year’s embarrassing enrolment problems will not be repeated when the sign-up season begins on Nov 15 for 2015 health insurance policies offered under the Affordable Care Act (ACA). But even as more insurance companies and millions more Americans enter the second year of the health insurance programme, the opportunity for critics to chip away at it will never be better when Republicans regain control of Congress in January. The presumptive Senate majority leader Mitch McConnell of Kentucky and John Boehner of Ohio, his House of Representatives counterpart, waited an entire day after their election victory this month to announce one of the first tasks for the new Congress: a vote to repeal “Obamacare”. Never mind that President Barack Obama has said he would veto such legislation if it reached his desk. And most Congressional observers, irrespective of their political sympathies, predict that McConnell will be unable to muster the 60 votes needed to override the veto. Rather than take aim at the whole law, smaller targets might be vulnerable to attack with a well-crafted strategy that could very well be dispatched with a veto-proof majority. For example, repealing a tax on medical devices such as artificial hips has been gathering bipartisan support, which could deprive Obamacare of US$28 billion over the next decade if passed. A further delay of the requirement that employers provide workers with health insurance or pay a penalty also has support. Tucking some anti-ACA measures into the budget bill may also be effective since they would be packaged with things Democrats want so much that an Obama veto could be overturned. www.thelancet.com Vol 384 November 15, 2014
A big drawback to this scenario is all too familiar to long-time budget watchers such as Thomas Miller, resident fellow at the conservative American Enterprise Institute. Congress has to actually approve a budget. “It will take some time but it could be done by summer, and that’s on a good day”, he told The Lancet. “If you want to get rid of every tax and every provision you have to offset that with some spending measures [to save money] and that’s a little harder to do”, he said.
“Rather than take aim at the whole law, smaller targets might be vulnerable to attack with a well-crafted strategy that could very well be dispatched with a veto-proof majority.” As the ACA begins its second year, critics expect that more Americans will see its flaws, and efforts to dismantle it will only be propelled by popular discontent. “Year two is sure to bring more broken promises”, a House Republican staffer told The Lancet. More health insurance policies that don’t meet the ACA’s requirements will be cancelled. Health-care costs will rise and newly insured patients will struggle to find doctors, he predicted. But after a year, despite a catastrophic rollout parodied on late-night comedy shows, supporters say the health law has not self-destructed. It provides health insurance, financial subsidies, and consumer protection and health-care reforms for millions of people, and with every new beneficiary, becomes harder to dislodge. So far, 16 million Americans have gained insurance coverage under the
ACA, including 8·7 million enrolled in Medicaid, the state and federal joint government health insurance programme for low-income families, which the health law expanded in states that agreed to do so. It also required insurers to offer free preventive care and screenings, and prohibited insurers from charging women more than men or denying coverage to people with pre-existing disorders, removed lifetime caps on coverage, and limited company profits. Another popular feature allows young adults to remain on their parents’ insurance plan until their 26th birthday. At this stage, Miller said some aspects of the law “can be chipped away but not probably blown up”.
Preparing for round 2 Under the law, all adults are required to have health insurance and, with some exceptions, those without it are penalised. People who don’t get health coverage through their jobs can buy policies through the online state or federal insurance exchanges from Nov 15 to Feb 15. To minimise the delays many experienced last year, federal officials who run the exchanges in 37 states have shortened the application and no longer require shoppers to spend time setting up accounts before they can review the plans. Although this month marks the second enrolment period, US Department of Health and Human Services (HHS) Secretary Sylvia Matthews Burwell has been eager to stress that it won’t be a rerun of last year. “It’s not year two”, she told reporters recently, because this is the first time the exchanges will be renewing current policies while also handling first-time applications. 1733
Saul Loeb/Staff
World Report
Sylvia Matthews Burwell, US Secretary for Health and Human Services
The 7·3 million Americans who have exchange plans will be automatically re-enrolled but officials are encouraging them to review other plans before the renewal of their current policy is finalised. Participating health-care providers, costs, and covered prescription drugs can change from year to year. Plus, 25% of policies are on sale for the first time. “That is the idea of an exchange—to make sure you get the best deal”, said Burwell. In addition to retaining current enrollees, administration officials will be working to sign up an estimated 9·9 million Americans for new coverage through the exchanges beginning next year, Burwell said. And she is still hoping some of the 23 states that have declined to join the ACA’s Medicaid expansion will reverse those decisions. Although a 2012 US Supreme Court ruling made participation optional, more than half of people who gained coverage under the health law did so by qualifying for Medicaid. It’s doubtful that many more states—dominated by anti-ACA Republicans—will agree to an expansion, even though the federal government pays for the full cost of new beneficiaries, with the states contributing 10% after 3 years. Although details of next year’s nationwide plan offerings were not available as The Lancet went to press, preliminary information from 15 states shows there was a slight decrease 1734
in monthly premiums, said Jennifer Tolbert, state health reform director at the Kaiser Family Foundation, an independent health research organisation, which analysed the plans. “However, that overall decline masks pretty wide variations: premiums are increasing by 8·7% in Tennessee and decreasing by 15·6% in Colorado”, Tolbert told The Lancet. “Before the ACA, double digit rate hikes were common”, an HHS spokeswoman told The Lancet. “Now, if an insurance company wants to increase a premium by 10% or higher, they have to publicly justify the increase. These types of rate hikes can be reviewed, challenged, and changed.”
“In addition to retaining current enrollees, administration officials will be working to sign up an estimated 9·9 million Americans for new coverage through the exchanges beginning next year...” Premiums vary based on where beneficiaries live, their age, and local health-care costs, among other factors, said Clare Krusing, a spokeswoman for America’s Health Insurance Plans, which represents more than 1300 insurers.
Picking the right plan But many newly insured beneficiaries are learning that premium prices can be deceptive. A low-premium plan may charge higher fees for doctor appointments and other services than a high-premium plan. “Sometimes paying a little bit more up front for the monthly premium can actually save you a lot of money later”, Rachel Klein, organisational strategy director at Families USA, a national health-care advocacy group, told The Lancet. And changing premiums are not the only reason organisations such as Families USA and federal officials are trying to persuade current enrollees to shop once again for coverage. Because most exchange plans cover
care from doctors and other providers in the plan’s provider network, they say it is important for beneficiaries to confirm that their doctors participate in their plan. Yet most exchange websites don’t allow consumers to identify only those plans that include their doctors. “Consumers should not have to shop with a blindfold on”, Lynn Quincy, associate director for health reform policy at Consumers Union, told The Lancet. But checking each insurer’s online directories, which may be outdated, or calling each company, can be a daunting task. Even doctors may not know the newest plans they participate in, she said.
New leader In addition to website improvements, the Obama Administration has made personnel changes, starting with Burwell, the nation’s top health official whom the president appointed in June, following the resignation of Kathleen Sebelius. Sebelius had been a leading advocate of the health law but was unable to deflect criticism of the technical problems that nearly derailed the exchange websites last year. Burwell, former chief of the Office of Management and Budget, has added technical staff and replaced the contractors who created the federal exchange website. She is also ensuring that the system is tested thoroughly before its Nov 15 debut, including the “back-end functions”. These are operations consumers don’t see that can cause massive delays if information is not communicated properly to their insurance company and the various government agencies that verify their identity, citizenship, income eligibility for financial assistance, and other application details. Still, Burwell has wisely been careful to dampen down expectations. “Will there be imperfections? Yes. Things will not be perfect”, she said. “But we are aiming for a strong consumer experience, and it will be better.”
Susan Jaffe www.thelancet.com Vol 384 November 15, 2014
Second round of enrolment begins under Affordable Care Act Ahead of the next phase of enrolment for insurance plans, Republicans vowed to target the health law following their election win. Susan Jaffe, Washington correspondent, reports. Federal health officials promise that last year’s embarrassing enrolment problems will not be repeated when the sign-up season begins on Nov 15 for 2015 health insurance policies offered under the Affordable Care Act (ACA). But even as more insurance companies and millions more Americans enter the second year of the health insurance programme, the opportunity for critics to chip away at it will never be better when Republicans regain control of Congress in January. The presumptive Senate majority leader Mitch McConnell of Kentucky and John Boehner of Ohio, his House of Representatives counterpart, waited an entire day after their election victory this month to announce one of the first tasks for the new Congress: a vote to repeal “Obamacare”. Never mind that President Barack Obama has said he would veto such legislation if it reached his desk. And most Congressional observers, irrespective of their political sympathies, predict that McConnell will be unable to muster the 60 votes needed to override the veto. Rather than take aim at the whole law, smaller targets might be vulnerable to attack with a well-crafted strategy that could very well be dispatched with a veto-proof majority. For example, repealing a tax on medical devices such as artificial hips has been gathering bipartisan support, which could deprive Obamacare of US$28 billion over the next decade if passed. A further delay of the requirement that employers provide workers with health insurance or pay a penalty also has support. Tucking some anti-ACA measures into the budget bill may also be effective since they would be packaged with things Democrats want so much that an Obama veto could be overturned. www.thelancet.com Vol 384 November 15, 2014
A big drawback to this scenario is all too familiar to long-time budget watchers such as Thomas Miller, resident fellow at the conservative American Enterprise Institute. Congress has to actually approve a budget. “It will take some time but it could be done by summer, and that’s on a good day”, he told The Lancet. “If you want to get rid of every tax and every provision you have to offset that with some spending measures [to save money] and that’s a little harder to do”, he said.
“Rather than take aim at the whole law, smaller targets might be vulnerable to attack with a well-crafted strategy that could very well be dispatched with a veto-proof majority.” As the ACA begins its second year, critics expect that more Americans will see its flaws, and efforts to dismantle it will only be propelled by popular discontent. “Year two is sure to bring more broken promises”, a House Republican staffer told The Lancet. More health insurance policies that don’t meet the ACA’s requirements will be cancelled. Health-care costs will rise and newly insured patients will struggle to find doctors, he predicted. But after a year, despite a catastrophic rollout parodied on late-night comedy shows, supporters say the health law has not self-destructed. It provides health insurance, financial subsidies, and consumer protection and health-care reforms for millions of people, and with every new beneficiary, becomes harder to dislodge. So far, 16 million Americans have gained insurance coverage under the
ACA, including 8·7 million enrolled in Medicaid, the state and federal joint government health insurance programme for low-income families, which the health law expanded in states that agreed to do so. It also required insurers to offer free preventive care and screenings, and prohibited insurers from charging women more than men or denying coverage to people with pre-existing disorders, removed lifetime caps on coverage, and limited company profits. Another popular feature allows young adults to remain on their parents’ insurance plan until their 26th birthday. At this stage, Miller said some aspects of the law “can be chipped away but not probably blown up”.
Preparing for round 2 Under the law, all adults are required to have health insurance and, with some exceptions, those without it are penalised. People who don’t get health coverage through their jobs can buy policies through the online state or federal insurance exchanges from Nov 15 to Feb 15. To minimise the delays many experienced last year, federal officials who run the exchanges in 37 states have shortened the application and no longer require shoppers to spend time setting up accounts before they can review the plans. Although this month marks the second enrolment period, US Department of Health and Human Services (HHS) Secretary Sylvia Matthews Burwell has been eager to stress that it won’t be a rerun of last year. “It’s not year two”, she told reporters recently, because this is the first time the exchanges will be renewing current policies while also handling first-time applications. 1733
Saul Loeb/Staff
World Report
Sylvia Matthews Burwell, US Secretary for Health and Human Services
The 7·3 million Americans who have exchange plans will be automatically re-enrolled but officials are encouraging them to review other plans before the renewal of their current policy is finalised. Participating health-care providers, costs, and covered prescription drugs can change from year to year. Plus, 25% of policies are on sale for the first time. “That is the idea of an exchange—to make sure you get the best deal”, said Burwell. In addition to retaining current enrollees, administration officials will be working to sign up an estimated 9·9 million Americans for new coverage through the exchanges beginning next year, Burwell said. And she is still hoping some of the 23 states that have declined to join the ACA’s Medicaid expansion will reverse those decisions. Although a 2012 US Supreme Court ruling made participation optional, more than half of people who gained coverage under the health law did so by qualifying for Medicaid. It’s doubtful that many more states—dominated by anti-ACA Republicans—will agree to an expansion, even though the federal government pays for the full cost of new beneficiaries, with the states contributing 10% after 3 years. Although details of next year’s nationwide plan offerings were not available as The Lancet went to press, preliminary information from 15 states shows there was a slight decrease 1734
in monthly premiums, said Jennifer Tolbert, state health reform director at the Kaiser Family Foundation, an independent health research organisation, which analysed the plans. “However, that overall decline masks pretty wide variations: premiums are increasing by 8·7% in Tennessee and decreasing by 15·6% in Colorado”, Tolbert told The Lancet. “Before the ACA, double digit rate hikes were common”, an HHS spokeswoman told The Lancet. “Now, if an insurance company wants to increase a premium by 10% or higher, they have to publicly justify the increase. These types of rate hikes can be reviewed, challenged, and changed.”
“In addition to retaining current enrollees, administration officials will be working to sign up an estimated 9·9 million Americans for new coverage through the exchanges beginning next year...” Premiums vary based on where beneficiaries live, their age, and local health-care costs, among other factors, said Clare Krusing, a spokeswoman for America’s Health Insurance Plans, which represents more than 1300 insurers.
Picking the right plan But many newly insured beneficiaries are learning that premium prices can be deceptive. A low-premium plan may charge higher fees for doctor appointments and other services than a high-premium plan. “Sometimes paying a little bit more up front for the monthly premium can actually save you a lot of money later”, Rachel Klein, organisational strategy director at Families USA, a national health-care advocacy group, told The Lancet. And changing premiums are not the only reason organisations such as Families USA and federal officials are trying to persuade current enrollees to shop once again for coverage. Because most exchange plans cover
care from doctors and other providers in the plan’s provider network, they say it is important for beneficiaries to confirm that their doctors participate in their plan. Yet most exchange websites don’t allow consumers to identify only those plans that include their doctors. “Consumers should not have to shop with a blindfold on”, Lynn Quincy, associate director for health reform policy at Consumers Union, told The Lancet. But checking each insurer’s online directories, which may be outdated, or calling each company, can be a daunting task. Even doctors may not know the newest plans they participate in, she said.
New leader In addition to website improvements, the Obama Administration has made personnel changes, starting with Burwell, the nation’s top health official whom the president appointed in June, following the resignation of Kathleen Sebelius. Sebelius had been a leading advocate of the health law but was unable to deflect criticism of the technical problems that nearly derailed the exchange websites last year. Burwell, former chief of the Office of Management and Budget, has added technical staff and replaced the contractors who created the federal exchange website. She is also ensuring that the system is tested thoroughly before its Nov 15 debut, including the “back-end functions”. These are operations consumers don’t see that can cause massive delays if information is not communicated properly to their insurance company and the various government agencies that verify their identity, citizenship, income eligibility for financial assistance, and other application details. Still, Burwell has wisely been careful to dampen down expectations. “Will there be imperfections? Yes. Things will not be perfect”, she said. “But we are aiming for a strong consumer experience, and it will be better.”
Susan Jaffe www.thelancet.com Vol 384 November 15, 2014