Consumer Power Report #387
This Commonwealth Fund study should be very worrisome to supporters of President Barack Obama’s law: Just one in four 19- to 29-year-olds is even aware of Obamacare’s exchanges.
From October 2013 through March 2014, young adults without affordable health insurance through an employer will be able to select a plan from their state’s insurance marketplace, with coverage beginning January 2014. Those with incomes under 400 percent of poverty will be eligible for subsidized coverage or Medicaid. The survey findings demonstrate just how critical outreach and education will be to inform young adults about their new options. Only 27 percent of 19-to-29-year-olds in the survey were aware of the marketplaces, with awareness lowest among those uninsured for some time during the year (19%) and those in low-income households eligible for subsidized coverage or Medicaid (18%). Awareness also varied by education levels: one-third of college graduates were aware of the marketplaces, compared with 20 percent of those with a high school degree or less.
The chart is on page 6. There’s another aspect of the Commonwealth study that shows how one of Obamacare’s earliest policy announcements is working against the success of the law. As I noted on Twitter and Sarah Kliff writes about, a larger percentage of young Republicans than young Democrats are aware of Obamacare’s details, and particularly the provision allowing young people to stay on their parents’ insurance through age 26. This policy is now working against Obamacare’s overall success, since those lower-income Republican youngsters would be more likely to end up in Obamacare’s exchanges if they weren’t on their parents’ plan. Without them in the risk pool, we’re likely to see higher rate shock for those who do dive in.
The failure of Obama’s effort to promote his law to the generation that helped make him president is clear here, and part of the challenge for the administration is attempting to push these exchanges and subsidies to a population that is disengaged – and when they do engage, are likely to find Obamacare is not a good deal for them in the short or long run, as Chris Conover argues.
A recent study by the National Center for Public Policy Research shows that: About 3.7 million of those ages 18-34 will be at least $500 better off if they forgo insurance and pay the penalty. More than 3 million will be $1,000 better off if they go the same route.
Consequently, many more will opt to pay the extremely modest tax rather than fork over many thousands of dollars to purchase coverage that became substantially more expensive for young people thanks to the misguided pricing rules imposed by Obamacare. The risk that the law will fail in an “adverse selection death spiral” thus has gotten much larger. This claim is not in dispute. Instead, progressives argue it is too narrow.
More on this here. But while Obamacare is bad for the young in these measures, it’s great for Obama’s other constituency: Washington insiders and big money lobbyists.
As the clock ticks down to the launch of President Barack Obama’s healthcare reform, hundreds of businesses, unions and advocacy groups are still pushing to win concessions on the far-reaching law. Restaurants want to increase the number of hours that define a full-time worker. Unionized electrical workers are seeking to change the treatment of health plans offered by multiple employers. Medical device companies hope to end a tax against them even though they are already paying that tax.
Lobbyists face slim odds of getting any additional changes to the law before October 1, when millions of Americans will be able to sign up for subsidized health insurance through online exchanges in each state. But there is an urgency to push for changes now, legislative experts say, because it will become much harder to do so once the law takes full effect in January. Lobbying may also give these groups leverage in negotiations down the road …
A Reuters review of lobbying records found that more than 500 companies, business groups, consumer advocates, unions and other organizations weighed in on the Affordable Care Act during the second quarter of this year.
Major lobbying firms such as Fierce, Isakowitz & Blalock, The Glover Park Group, Alston & Bird, BGR Group and Akin Gump can all boast an Affordable Care Act insider on their lobbying roster – putting them in a prime position to land coveted clients … Veterans of the healthcare push are now lobbying for corporate giants such as Delta Air Lines, UPS, BP America and Coca-Cola, and for healthcare companies including GlaxoSmithKline, UnitedHealth Group and the Blue Cross Blue Shield Association.
Ultimately, the clients are after one thing: expert help in dealing with the most sweeping overhaul of the country’s healthcare system in decades …
The voracious need for lobbying help in dealing with ObamaCare has created a price premium for lobbyists who had first-hand experience in crafting or debating the law. Experts say that those able to fetch the highest salaries have come from the Department of Health and Human Services (HHS) or committees with oversight power over healthcare.
This is the Obama approach to governance: Pass burdensome regulations on everyone then dole out favors to your allies, as the powerful and wealthy work to exempt themselves from the rules.
— Benjamin Domenech
IN THIS ISSUE:
The Wall Street Journal reports:
California’s new health-insurance exchange, the biggest of the state marketplaces emerging under the federal health-care overhaul law, said there was a possibility consumers won’t initially be able to enroll in coverage online when it is launched on Oct. 1.
Peter V. Lee, executive director of Covered California, the state agency creating the exchange, said Thursday in a meeting of its board that the agency potentially would “phase in support” for the exchange, starting with allowing offline means of sign-up and later adding the ability to fully enroll online.
Either way, consumers are expected to be able to obtain health plans by speaking with counselors on the phone or in person.
Mr. Lee said the exchange agency is “absolutely confident that we will be live and serving consumers Oct. 1.” He pointed to Oregon, where the exchange has said consumers won’t be able to access it online in the first few weeks after Oct. 1, and said California’s exchange has “not yet made that call at this point.” But he wanted to “make sure we’re managing expectations” about its rollout.
Earlier, the California exchange had begun warning insurers that there was a possibility it wouldn’t be able to sign up consumers for coverage online at launch. A spokesman for the California exchange said the technology for enrollment is still being tested, and so far tests “haven’t revealed any major issue that can’t be addressed.” The exchange agency will have a clearer picture in the first week of September, he said.
SOURCE: Wall Street Journal
Romneycare doesn’t like Obamacare:
Conventional wisdom has held that Obamacare’s impact on Massachusetts will be small. Some high profile academics have gone as far as to attack presidential candidates with colorful language if they suggest otherwise. Well, the conventional wisdom has had a nuclear bomb dropped on its head with the release of an independent analysis by the major insurance companies in Massachusetts. The implications are clear: the ACA will supply a rough ride for many small companies in the state. Unlike other states where the rate shock will be most pronounced in the individual marketplace and/or for younger adults, the ACA will cause the most turmoil in the much larger small business market in the Bay State. For some companies in Massachusetts, the shock will be a premium spike of over 100%, when you include healthcare trend.
The report was commissioned by the Massachusetts Association of Health Plans (MAHP) and Blue Cross Blue Shield of Massachusetts, and conducted by Wakely Consulting group. All parties involved have spoken favorably about the ACA for years. In fact, Wakely Consulting was founded by the first Massachusetts Connector executive director John Kingsdale, who advised the Obama Administration on the ACA, and has made millions from ACA related consulting contracts. These leaders are far from right-wing ideologues. In fact, many have been vocal supporters of the ACA, dating back to the legislative debate.
Across the board, leaders of the insurance industry in Massachusetts have supported the ACA, until recently. Privately the tone in the state has changed as carriers have become more familiar with the federal law, and regulations have come down from Washington. The frequency and urgency of closed door meetings increased as state officials discovered the damage the ACA could inflict on local insurance markets. State officials even went as far as to predict “extreme premium increases” in a letter to CMS. The issue came to a head recently when the Democrats in the legislature passed an amendment to force Governor Deval Patrick to publicly request a waiver from a portion of the federal law.
Latest from Iowa:
Gov. Terry Branstad filed a waiver request with federal officials on Friday, seeking expedited approval for a statewide program to expand access to health care for thousands of lower-income Iowans.
“Our plan passed with bipartisan support and is designed to increase access, drive personal health ownership, and reform our health care delivery program to pay for quality, not quantity, of health care delivered,” Branstad said in a letter to Kathleen Sebelius, secretary of the U.S. Department of Health and Human Services.
The legislation approved by Iowa lawmakers in May creates a new public health care program for individuals earning up to 100 percent of the federal poverty level and fully subsidizes the purchase of private insurance for those making up to 138 percent.
The hybrid approach represents a compromise between Democrats and Republicans. The parties, which hold majorities in the Senate and House, respectively, were at odds for much of the recent session over how to respond to the federal Affordable Care Act. The law directs states to expand existing Medicaid programs to individuals earning up to $16,000 a year …
Premium contributions, instead of traditional Medicaid co-pays, played a key role in the bipartisan compromise, Branstad said in the letter. Many individuals involved in the compromise felt strongly that the premiums can help drive personal awareness and ownership of health outcomes, he added.
“In short, the premium component was clearly outlined in our state law and must be part of the waiver approval” for the Iowa program to move forward, Branstad said.
Greg Scandlen is dead on:
Many people eligible for exchange coverage do not have bank accounts or credit cards. That is why inner city neighborhoods have storefronts that cash checks and issue money orders. Many people have surges of income, working one month but not the next, or collecting commissions one month and not the next. Many people have financial emergencies – their transmission breaks down or they are out sick for two weeks, or their boyfriend moves out of the house – they don’t have the money to pay their premium this month. We know these things will happen – a lot.
So far, the regulations coming out of Health and Human Services are not encouraging (see pages 18337, 18387, 18394 and 18471 of the Federal Register.) As you might expect, the regulations are being written by people with nice bureaucratic jobs and steady paychecks. They have no idea what it is like to scramble to make ends meet.
It’s not that they haven’t tried. Lord knows they have issued more regulations than it would take to put a man on the moon. But they are illustrating the limits of the regulatory process. Regulations always mean “you must do Y, but you may not do X” – as if every contingency can be anticipated from an office in Washington. So, rather than allowing insurance carriers to collect premiums in the ways they know will work, HHS has created a whole new and very restrictive method that must be followed to a “T.”
In this case, the bureaucrats realize that some people will have a hard time paying their bills, even when the bills are partially subsidized. So they have generously provided for a 90-day grace period for paying premiums – but only for people who are getting a federal subsidy. None of this applies to people who are not subsidized.
The problem with a 90-day grace period for premium payment is that at the end of it you must pay for three months of premiums, when you couldn’t afford to pay one month in the first place. A lot of people won’t be able to do that, but meanwhile they have been running around with an insurance card receiving health services.
What then? Who is on the hook for those services? HHS has decided to split the baby. The insurance company will have to pay for the first month of non-coverage, but providers (doctors and hospitals) will have to absorb the costs incurred for the second two months. That could be a whole lot of money. The (formerly) insured person will be canceled after three months, but they get to re-enroll again at the end of the year without penalty. (And we were told one of the purposes of this law was to solve the “free-rider” problem. Oh, well.)
Along with paying for services during the first month of the delinquency, the insurer must: 1) notify HHS of the non-payment; 2) notify providers of the possibility of denied claims during the second and third months; 3) notify the insured that he/she is delinquent; 4) continue to collect the advanced tax credit on behalf of the policyholder; 5) return the tax credit for the second and third month to the Treasury; 6) issue a termination notice to the insured at the end of the grace period. Oh, and the carrier must also determine whether the insured has a disability as defined by the Americans With Disabilities Act, and make “reasonable accommodations” for such individuals. These are pretty substantial administrative burdens, and the costs will aggravate the Minimum Loss Ratio requirement for the carrier.
So, how many people do you suppose will do this? I would wager just about everybody. Why not? You can get 12 months of coverage for nine months of premiums and suffer absolutely no penalty.
In coming years, the U.S. could see growing shortages in the availability of primary care physicians. With the number of individuals seeking care increasing and the current medical system continuing to incentivize physicians to specialize, the number of available PCPs will decline proportional to the population. To fill that gap, Ezra Klein and others have asserted that expanded scope of practice will allow nurse practitioners to serve as viable substitutes for primary care shortages. While NPs serve a vital role in the system and meet need, the argument that they are a one-to-one substitute for PCPs (but for the greedy doctors and pesky regulations holding them back) is singular and shortsighted.
The argument also fails to address broader policies that influence both NP and PCP behaviors. Policies that unjustifiably lead to the unequal distribution of caregivers, location or expertise, inherently parlay into unequal care for patients. Sadly, a broader scope than “freeing nurse practitioners” is necessary to meet primary care needs, as NPs are compliments, not substitutes. Policy must address the need for more primary care and assist to realign the system to meet our country’s basic care and equality through redistribution.
Primary care is the foundation of the evolving health care system, with equal access the intended goal of the ACA. Along the way to meeting future demand for primary care, NPs can be increasingly utilized to meet the needs of Americans and improve the health of the nation. And let it be known I am a strong proponent and supporter of nurse practitioners and all non-physician providers and coordinators. However, the argument that most NPs practice in primary care and will fill the primary care gap, estimated at about 66 million Americans, is inaccurate. It isn’t a 1:1 substitute, especially given that models of the solo practitioner are vanishing in lieu of complementary and team-based care.