Tag: Affordable Care Act (ACA)

Uninsured rate stays stable in 2018



Dive Brief:

  • The percentage of people without health insurance remained relatively steady over the past year despite efforts to repeal the Affordable Care Act and attempts to curb coverage in Washington and at state levels.
  • The latest statistics from the CDC show that from January to March of this year 28.3 million people (8.8%) were uninsured. That’s compared to 29.3 million people (9.1%) a year ago. There are 20 million fewer people without insurance compared to 2010, when the ACA was enacted.
  • More consumers shifted to high-deductible health plans (HDHPs) in the first quarter. The report found that nearly half (47%) of Americans under age 65 with private health insurance had a high-deductible plan, an upward trend since 2010.

Dive Insight:

CDC said 12.5% of adults aged 18-64 didn’t have insurance in the first three months of 2018. Nearly 20% had public coverage and 70% were covered by private health insurance. Of the 138.6 million adults with private health insurance, 8.3 million of them (4.2%) received coverage through ACA exchanges.

Nearly 5% of children were uninsured, 42% had public insurance and almost 55% had private health insurance coverage.

A person’s race continues to play a factor in health insurance. Nearly one-quarter of Hispanics lacked coverage in the first quarter. The Hispanic population has seen significant decreases in the percentage of uninsured adults since 2013 when it stood at more than 40%, but the percentage is still higher than other groups. The percentage decreased another three percentage points over the past year from 27.2% to 24.2%. The uninsured rates for other groups remained consistent from last year.

CDC also found that people in Medicaid expansion states were less likely to be uninsured compared to non-expansion states. The percentage of uninsured adults in expansion states decreased from 18.4% in 2013 to 8.7% in 2018. Non-expansion states’ rates fell from 22.7% in 2013 to 17.5% in 2015 before increasing to 19% in 2017. There was a slight percentage drop in 2018 (18.4%), which is still more than double the percentage in expansion states.

Meanwhile, in private insurance, payers and employers increasingly turn to HDHPs, which have higher out-of-pocket costs and usually lower premiums. Payers and employers have moved more people into those plans as a way to contain costs and give consumers “more skin in the game.”

CDC found that of the 47% of people enrolled in an HDHP, only 21.3% were in a consumer-directed health plan with a health savings account. About one-quarter had a plan without an HSA, which lets people save tax-free funds for their healthcare. Employers often contribute to those accounts.

CDC said the number of people in a consumer-directed plan tripled from 7.7% in 2010 to 21.3% in 2018, including a jump from 18.2% in 2017 to 21.3% this year. The percentage of people without an HSA didn’t change significantly over the past year. This shows that employers and payers are increasingly providing tools like HSAs to help people afford care.

Out-of-pocket costs remain a concern for Americans and can result in delaying care.

A recent Commonwealth Fund report found that one-third of American adults aren’t very or somewhat confident they can afford to pay for a serious illness. Only about half of people who earn less than $30,150 are confident they can afford that care.

They have reason to worry. Peterson-Kaiser Health System Tracker recently reported that payments for deductibles and coinsurance increased faster than the total cost for covered costs between 2006 and 2016. The report showed that total out-of-pocket spending increased by 54% in that period from an average of $525 in 2006 to $806 in 2016.

OPINION: How I Was Wrong About ObamaCare

I was wrong. Wrong about an important part of ObamaCare.

When I joined the Obama White House to advise the president on health-care policy as the only physician on the National Economic Council, I was deeply committed to developing the best health-care reform we could to expand coverage, improve quality and bring down costs. We worked for months to pass this landmark legislation, and I still count celebrating the passage of the Affordable Care Act with the president one balmy spring night in 2010 as one of my greatest Washington memories.

What I got wrong about ObamaCare was how the change in the delivery of health care would, and should happen. I believed then that the consolidation of doctors into larger physician groups was inevitable and desirable under the ACA. I joined my White House health-care colleagues – Ezekiel Emanuel and Nancy-Ann DeParle – in writing a medical journal article arguing that “these reforms will unleash forces that favor integration across the continuum of care.” We added that “only hospitals or health plans can afford to make the necessary investments” needed to provide the care we will need in a post-ACA world.

Well, the consolidation we predicted has happened: Last year saw 112 hospital mergers (up 18 percent form 2014). Now I think we were wrong to favor it.

I still believe that organizing medicine into networks that can share information, coordinate care for patients and manage risk is critical for delivering higher-quality care, generating cost savings and improving the experience for patients. What I know now, though, is that having every provider in health care “owned” by a single organization is more likely to be a barrier to better care.

Over the past five years, published research, some of it well summarized on a Harvard Medical School site, has indicated that savings and quality improvement are generated much more often by independent primary-care doctors than by large hospital-centric health systems.

Look at accountable-care organizations (ACOs), in which doctors and health-care providers come together to provide complete care for an individual and are compensated for keeping them healthy and generating savings. Based upon the latest data the Centers for Medicare and Medicaid Services has released, from 2014, independent physician-led ACOs, like the Rio Grande ACO on the Texas border, are outperforming ACOs from many of the most famous health systems. Johns Hopkins Hospital in Baltimore has been ranked as one of the top three health systems in the nation, but its ACO failed to achieve shared savings in 2014.

Small, independent practices know their patients better than any large health system ever can. They are going up against the incumbent and thus are driven to innovate. These small businesses can learn faster without holding weeks of committee discussions and without permission from finance, legal and IT departments to make a change.

More often than not, one of the most important changes these practices make is embracing technology. The ability to store, analyze and make sense of data has now become so easy and inexpensive that all physicians can use “big data.”

In my White House days, we believed it would take three to five years for physicians to use electronic health records effectively. We were wrong about that too. At every opportunity, organized medicine has asked to delay and lower thresholds for tracking and reporting basic quality measures; yet they have no reason to delay.

In the ACOs run by Aledade, which advises small medical practices (I sit on its board), we have found that independent primary-care doctors are able to change their care models in weeks and rapidly learn how to use data to drive savings and quality. For small practices, it does not take years to root out waste, rewire referrals to providers who charge less but deliver more, and redesign schedules so patients can see their doctors more often to avert emergency-room visits and readmissions.

Recognizing the strength in the small practices, the federal government needs to write rules that make it easier for them to thrive under ObamaCare and don’t tip the scales toward consolidation. That means introducing payment models that limit losses for small providers to the Medicare dollars they receive rather than total spending, and which rely on multiyear benchmarks instead of single-year swings. It also means comparing small practices to other small ones—instead of to large health systems with large balance sheets—when determining if a practice deserves bonus payments for savings.

Large health systems deliver “personalized” care in the same way that GM can sell you a car with the desired options. Yet personal relationships of the kind often found in smaller practices are the key to the practice of medicine. They are the relationships that doctors want to forge with patients, and vice versa. It may sound old-fashioned, but what I have learned is that we do not need to sacrifice this unique feature of our health-care system as we move forward in adapting new value-based payment models and improving the health of patients.

House Republicans’ ACA lawsuit moves forward

Just months after the Affordable Care Act (ACA) survived a serious legal threat at the Supreme Court, a federal judge gave a boost Wednesday to what could be yet another a major court challenge to the healthcare law.

U.S. District Judge Rosemary Collyer decided House Republicans have standing to sue over their allegation that the administration is illegally spending money that Congress never appropriated for the law’s cost-sharing provisions. Those provisions include reduced deductibles, copays and coinsurance for many beneficiaries depending on income.

The House had to prove it was injured by the administration’s actions in order to gain standing. Collyer, who was nominated by President George W. Bush, wrote that if that allegation regarding is appropriations is true, “the House has been injured in a concrete and particular way that is traceable to the secretaries and remediable in court.”

“As the House argues, Congress cannot fulfill its constitutional role if it specifically denies funding and the executive simply finds money elsewhere without consequence,” Collyer wrote. “Indeed, the harm alleged in this case is particularly insidious because, if proved, it would eliminate Congress’s role via-a-vis the executive.”

The judge also wrote, however, that the House does not have standing to sue over a separate allegation in the lawsuit that the administration had no right to delay the law’s employer mandate, which requires companies with 50 or more employees to provide coverage.

The Obama administration has argued that insurers have a legal right to reimbursement for cost-sharing reductions mandated under the law, citing a part of the statute that says HHS “shall make periodic and timely payments to the issuer equal to the value of the reductions.”

The administration also argued that the House shouldn’t be granted standing because the fight is essentially a political one.

House Speaker John Boehner (R-Ohio) issued a statement praising Collyer’s opinion. “The president’s unilateral change to Obamacare was unprecedented and outside the powers granted to his office under our Constitution,” Boehner said.

The U.S. Justice Department said it plans to appeal the decision.

“The law is clear that Congress cannot try to settle garden variety disputes with the Executive Branch in the courts,” said White House Deputy Press Secretary Jen Friedman, in a statement. “This case is just another partisan attack—this one, paid for by the taxpayers—and we believe the courts will ultimately dismiss it.”

Now that the case is moving forward, some experts say it could pose a significant threat to the law itself.

About 56% of Americans who receive coverage through the ACA’s insurance exchanges get cost-sharing reductions, lowering the amounts they pay out-of-pocket for deductibles, coinsurance and copayments, according to the CMS. That equals about 5.6 million people.

Without the reductions, “most of the people in the exchanges are not going to want to participate in the exchanges because most exchange participants are receiving cost-sharing subsidies,” said Michael Cannon, a director of health policy studies for the libertarian Cato Institute and a key influence behind the lawsuit that led to the Supreme Court’s King v. Burwell opinion in June. If many healthy people drop out of the exchanges because cost-sharing subsidies disappear, then premiums may rise for those left in the exchanges, he said.

It’s a concern that’s similar to the one many expressed in the debate about King v. Burwell. The challengers in that case argued that the law said insurance premium subsidies should only be available to Americans in states with their own exchanges. The Supreme Court, however, sided with the government in that case in a 6-3 decision that many experts say saved the overall law.

Tim Jost, a law professor at Washington and Lee University who supports the ACA, said healthcare could become unaffordable for many Americans if House Republicans prevail in this latest case.

“If the insurers are required to provide cost sharing reductions but not reimbursed, that’s going to cause very serious financial problems for the insurers, and if they cease to provide cost-sharing reductions, it’s going to cause very, very serious problems for a lot of Americans,” Jost said.

Then again, Jost said, if the House succeeds in the lawsuit, Congress might just have to appropriate the money for cost-sharing because it’s required under the law.

There are other reasons, too, that a Republican victory in the case might not shake the foundations of the law as much as a loss for the government in King v. Burwell would have.

Richard Kogan and Edwin Park of the left-leaning Center on Budget and Policy Priorities recently wrote that beneficiaries will continue to receive cost-sharing reductions regardless of the case’s outcome because they are an entitlement under the ACA.

If Congress refused to appropriate money for the reductions, insurers could then seek relief in the U.S. Court of Federal Claims and would likely win, Kogan and Park wrote.

Meanwhile, Collyer’s ruling on standing may get reversed on appeal before the lawsuit is decided.

Jost said her decision runs contrary to precedent. “She basically concludes that she’s in uncharted waters and can decide for herself what the law should be,” Jost said.

Collyer writes in the opinion that the case is unique and asserts that her decision to grant the House standing won’t open any “floodgates, as it is inherently limited by the extraordinary facts of which it was born.”

Kermit Roosevelt, a University of Pennsylvania constitutional law expert, said it’s difficult to predict how the case might unfold given that most similar questions haven’t made it past the hurdle of establishing standing. Roosevelt said the case might end up making new law.

“There are also interesting political considerations given that the Supreme Court has heard two challenges to Obamacare,” Roosevelt said. “I wonder how much appetite they have for more of them.”

Supreme Court upholds subsidies in King v. Burwell

Insurance premium subsidies will continue to flow to Americans in all states under the Affordable Care Act, the U.S. Supreme Court decided 6-3 in King v. Burwell on Thursday.

The justices sided with the Obama administration in the historic decision, saying the healthcare law allows Americans in all states—not just those that established their own exchanges—to receive the subsidies.

Chief Justice John Roberts and Justice Anthony Kennedy were the swing votes in the case, siding with the more liberal justices.

“Congress passed the Affordable Care Act to improve health insurance markets, not to destroy them,” Roberts wrote in the opinion. “If at all possible, we must interpret the act in a way that is con­sistent with the former, and avoids the latter.”

An estimated 6.4 million Americans receive the subsidies in the 34 states that don’t have their own exchanges, in many cases relying on them to afford their health insurance, according to HHS.

Many had worried a decision in the opposite direction would lead to a dramatic spike in the nation’s uninsured and the disintegration of the healthcare law itself.

The challengers in the case pointed to one part of the law that says subsidies are available only to those who enroll through an “exchange established by the state.” The federal government, however, argued that the law’s purpose is clear in allowing Americans in every state to be eligible for subsidies and that other parts of the law indicate that.

In siding with the Obama administration Thursday, the justices refused to consider the phrase “exchange established by the state” in isolation. Instead, they looked at the broader context and structure of the law.

“In this instance, the context and structure of the act compel us to depart from what would otherwise be the most natural reading of the pertinent statutory phrase,” Roberts wrote in the opinion.

He wrote the subsidies “are necessary for the federal exchanges to function like their state exchange counterparts, and to avoid the type of calamitous result that Congress plainly meant to avoid.”

The Internal Revenue Service has interpreted the law to allow subsidies in all states, but the four individual plaintiffs in the case said that interpretation was wrong. The Supreme Court, however, refused to entertain that idea in their opinion.

The justices declined to apply what’s known as the Chevron doctrine, an oft-cited precedent that says federal agencies must follow the letter of the law where the law is clear. Under the doctrine, if a law is ambiguous, courts must defer to a government agency’s reasonable interpretation of it.

The justices said in their opinion it’s extremely unlikely Congress would have delegated interpretation of the law to the IRS, so the Chevron doctrine wasn’t appropriate for this case.

“Had Congress wished to assign that question to an agency, it surely would have done so ex­pressly … It is especially unlikely that Con­gress would have delegated this decision to the IRS, which has no expertise in crafting health insurance policy of this sort,” Roberts wrote in the opinion.

Some had speculated that if the court had used the Chevron doctrine to decide the case—finding the language of the law ambiguous and allowing the IRS’ interpretation—future presidential administrations could have re-interpreted the statute and pulled the plug on subsidies.

Roberts didn’t seem to want to expose the law to that type of uncertainty by applying the Chevron doctrine, said Ankur Goel, a partner with McDermott Will & Emery who co-authored an amicus brief siding with the government on behalf of the American Public Health Association.

“Here, it’s really because of the magnitude of the issue, the magnitude of the dollars that are being expended,” Goel said. “To say different administrations could change the ruling didn’t seem to Justice Roberts like the right answer.”

Last summer, a 4th U.S. Circuit Court of Appeals panel in Virginia unanimously ruled in favor of the administration in King v. Burwell, saying subsidies should be allowed in all 50 states.

Dissenting on the decision were Justices Antonin Scalia, Samuel Alito and Clarence Thomas.

Chip Kahn, CEO of the Federation of American Hospitals, called the decision “welcome news” in a statement Thursday.

“The decision secures healthcare coverage for millions of Americans,” Kahn wrote. “Protecting patient coverage provides peace of mind to so many and helps ensure their access to the needed care at the right time.”

Rich Umbdenstock, CEO of the American Hospital Association, called the decision a “significant victory.”

“In the short time the subsidies have been available, hardworking people who are sick, need care for chronic conditions or want preventive care have been able to seek care more easily,” Umbdenstock said in the statement. “Most significantly, providing access to primary and preventive care helps improve the health and well-being of individuals, family and communities.”

The three dissenting justices, however, criticized the majority for performing “somersaults of statutory interpretation” in their dissent, written by Scalia.

Scalia said King v. Burwell, along with the last Supreme Court opinion over the ACA in 2012, “will publish forever the discouraging truth that the Supreme Court of the United States favors some laws over others, and is prepared to do whatever it takes to uphold and assist its favorites.”

Scalia argued that the phrase “established by the state” is clear. Context matters, he said, but should be used as a tool for understanding laws, “not an excuse for rewriting them.” He added that the context of the ACA actually undermines the majority’s reading.

“Words no longer have meaning if an exchange that is not established by a state is ‘established by the state,’ ” Scalia wrote. “It is hard to come up with a clearer way to limit tax credits to state exchanges than to use the words ‘established by the state.’ ”

But Tim Jost, law professor at Washington and Lee University and a prominent ACA proponent, countered that the majority made the only logical decision.

“It was obvious from the beginning that Congress intended the federally facilitated as well as state exchanges to grant premium tax credits, and if the court was willing to read the statute as a whole and not just focus on four words, it could not avoid that conclusion,” Jost said.

Others, however, agreed with Scalia.

“In the end, the court once again had to rewrite the plain text of Obamacare, in the words of Justice Scalia, to save the Affordable Care Act,” said Josh Blackman, an assistant professor at South Texas College of Law who filed an amicus brief in the case on behalf of the Cato Institute siding with the challengers.

Blackman added that it was curious that Roberts pointed out in his opinion that key parts of the law were written behind closed doors rather than through the traditional legislative process. Roberts also noted that much of the act was passed using a complex budgetary procedure known as reconciliation, which limited chances for debate and amendment.

“Basically this law was not passed in the manner that was appropriate for such a significant piece of legislation,” Blackman said. “The court said we’re not going to hold them to it.”

Obama remains optimistic on ACA future as King v. Burwell looms

President Barack Obama remains optimistic that the Affordable Care Act will remain the law of the land for years to come despite a pending Supreme Court decision that could derail the legislation.

Before the end of June, the high court is expected to issue a ruling in King v. Burwell, in which ACA opponents claim that only states with their own exchanges are eligible to receive subsidies. If the court rules against the administration, an estimated 6.4 million Americans in states using the federal exchange would lose subsidies totaling $1.7 billion, according to the Kaiser Family Foundation.

President Obama didn’t explicitly address the pending case during his remarks at the closing of the Catholic Hospital Association Conference, but spoke about the law being around for years to come, to the point that his own daughters would have coverage options after they turned 26.

“There’s something deeply cynical about the ceaseless partisan attempts to roll back progress,” Obama said during the speech in Washington D.C. Tuesday. “I understand people being skeptical or worried before the law was passed and there was no reality to examine. But now that we can see millions of people having health care—and all the bad things that were predicted didn’t happen—you’d think it was time to move on.”

He went on to say that most people who have obtained coverage as the result of the law are generally happy with their care and the premiums they pay, and noted they would have been as much as $1,800 more today had trends over the decade before the ACA passed continued.

“In the years to come, countless Americans who can now buy plans that are portable and affordable on a competitive marketplace will be free to chase their own ideas, unleash new enterprises across the country, knowing they’ll be able to buy health insurance,” Obama said.

The CHA, which is celebrating it’s 100th anniversary during this week’s conference, was one of Obama’s most reliable allies in getting the Affordable Care Act passed. During his speech, Obama said he could not have gotten the law passed without CHA President and CEO Sister Carol Keehan. Keehan wrote in a 2013 Modern Healthcare op-ed that the law would help Catholic systems advance their mission of caring for the underserved.

Beyond ACA, GOP presidential candidates differ on healthcare

The burgeoning group of official and unofficial GOP presidential candidates all agree on one thing when it comes to healthcare policy: They really, really hate Obamacare.

Former Florida Gov. Jeb Bush called the law that has reduced the number of uninsured Americans by nearly 17 million a “monstrosity.”

Dr. Ben Carson, the retired African-American pediatric neurosurgeon, said the Affordable Care Act is “the worst thing that has happened in this nation since slavery.”

But differences are emerging on the candidates’ approaches to strengthening the long-term finances of Medicare, with former Arkansas Gov. Mike Huckabee bucking Republican orthodoxy. That could become an important fissure in the GOP presidential primary campaign.

The discussion about the ACA is unlikely to gain more nuance during the GOP primaries. That’s because there’s no political payoff to saying anything but horrible things about President Barack Obama’s signature healthcare reform law, which remains deeply unpopular among Republican activists. “The only way a Republican gets in trouble is if they say they want to somehow make the ACA work better,” said Robert Blendon, an expert on healthcare politics at Harvard University. “There’s just no constituency in Republican primaries for that position.”

Some candidates, while providing few details, have offered clues on their vision for repealing and replacing the ACA. Sen. Marco Rubio (R-Fla.) has proposed a three-part plan including premium tax credits for individuals that he says would be comparable to the tax breaks for employer-based health plans.

He also backs a menu of long-standing conservative policy nostrums, including allowing insurers to sell plans across state lines and expanding health savings accounts.

Bush said in March that the government’s primary role in healthcare should be to provide access to high-deductible, “catastrophic” coverage. He advocates replacing the ACA “with a model that is consumer-directed, where consumers, where patients, have more choices … where the subsidies, if there were to be subsidies, are state-administered … where people have more customized types of insurance based on their needs.”

But Bush’s tenure as a well-paid board member for Tenet Healthcare Corp.—which has strongly supported coverage expansion efforts under the ACA—has prompted skepticism among some conservatives about his anti-Obamacare bona fides. Bush stepped down from the board in December, when he began actively exploring a presidential campaign.

The GOP field, with two major exceptions, is also unified in rejecting the ACA’s Medicaid expansion. Louisiana Gov. Bobby Jindal and Wisconsin Gov. Scott Walker have boasted about their refusal to take the federal dollars, which hasn’t been broadly popular in their own states. In contrast, New Jersey Gov. Chris Christie and Ohio Gov. John Kasich supported Medicaid expansion in their states.

Kasich, who has strongly signaled his interest in running, has been a passionate evangelist for Medicaid expansion, which has angered many in the GOP. “Put yourself in the shoes of a mother and a father of an adult child that is struggling,” he told a Republican legislator during his state’s debate over expansion in 2013. “Walk in somebody else’s moccasins. Understand that poverty is real.”

Differences also are emerging over Medicare. Christie has made major Medicare and Social Security restructuring the centerpiece of his agenda, proposing to gradually raise the Medicare eligibility age to 69 and hike premiums for seniors with incomes above $85,000. His proposal is seen as an effort to revive his scandal-marred presidential prospects, but it could alienate the GOP base of older voters.

Last month, Bush and Rubio also came out in favor of raising the retirement age for future Medicare beneficiaries. “The math is unmistakable,” Rubio said. Two other declared candidates, Sens. Rand Paul (R-Ky.) and Ted Cruz (R-Texas), have long backed gradually raising the Medicare age. None of them have addressed the Congressional Budget Office’s 2013 finding that raising the Medicare age to 67 would have only a modest effect on the federal deficit because it would lead to higher spending on Medicaid and ACA premium subsidies.

But Huckabee has staked out a sharply different, populist stance on Medicare, vowing to protect the program from cuts. “I’ll never rob seniors of what our government promised them and even forced them to pay for,” he said last week.

That could cause headaches for other Republican candidates because most have embraced the ambitious entitlement restructuring agenda laid out by Rep. Paul Ryan (R-Wis.). Medicare is highly popular with voters, especially seniors, and Democrats effectively pummeled the GOP ticket of Mitt Romney and Paul Ryan on the Medicare issue during the 2012 president campaign.