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August 17, 2015

Washington Health Policy Week in Review Archive 3b9a8fc6-8144-413a-8567-ae75863f84a2

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Uninsured Rate Fell by One-Third Since 2013, CDC Says

By Melanie Zanona, CQ Roll Call

August 12, 2015 -- Mounting evidence suggests that more people are benefiting from the 2010 health care law, with the number of Americans without medical coverage declining by one-third, or 15.8 million people, since 2013, according to the latest report from the Centers for Disease Control and Prevention (CDC).

The number of people without health insurance dropped from 36 million last year to 29 million between January and March 2015, the CDC said Wednesday. The data is based on a National Health Interview Survey of 26,121 people from the first quarter of this year.

Meanwhile, the CDC said some of the most significant coverage gains since 2013 were found among low-income people and Hispanics.

The data comes on the heels of a Gallup Inc. report released earlier this week that found about 11.7 percent of people in the United States did not have health coverage in the first half of 2015. That's down from about 18 percent of residents at the start of 2014, when the Affordable Care Act's major coverage expansions took effect.

Democrats are likely to tout the data as a sign that the health care overhaul is working as Republicans attempt to use budget reconciliation and other legislative vehicles to gut the law.

"Since the Affordable Care Act began to take effect, the uninsured rate has dropped by about one-third, and almost every American has benefited from improved protections no matter where or how they bought health insurance," said Health and Human Services spokesman Ben Wakana. "Women can no longer be charged more than men, people with preexisting conditions cannot be denied coverage, and young adults up to 26 years of age can be insured on their parents' policies. The price of health care has risen at the slowest rate in 50 years, and the American people want us to build on the progress we have made."

The Supreme Court delivered President Barack Obama a legal victory this summer when it ruled federal subsidies for health insurance should be available in all states, regardless of whether they set up their own marketplaces. But Republicans use the law as a rallying cry to generate enthusiasm among their core supporters.

The CDC data also found that among adults aged 18–64, the number of uninsured decreased from 16.3 percent in 2014 to 13 percent in the first three months of 2015. The percentage of children with private coverage increased from 52.6 percent in 2013 to 56.3 percent in the first quarter of 2015, reversing a 14-year trend of declining rates of private coverage, the report notes.


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Health Coverage Gains May Influence Rhetoric

By Rebecca Adams, CQ Roll Call

August 10, 2015 -- Democrats seized on a new Gallup analysis showing that the number of Americans without medical coverage remains low as evidence that more people are benefiting from the controversial health care law.

Several Democrats re-tweeted the mid-year Gallup Inc. report released Monday, which said about 11.7 percent of people in the United States did not have health coverage in the first half of 2015. That's down sharply from about 18 percent of residents at the start of 2014, when the health care law's major coverage expansions took effect. 

"Political attacks from the Republican right have put millions of people's health care in jeopardy, but, luckily, they have failed in Congress and in the Supreme Court," said House Energy and Commerce top Democrat Frank Pallone Jr., in a statement to CQ Roll Call. "I hope that now, with even greater evidence that the ACA is working and saving lives, my Republican colleagues can move on and accept the transformative and positive impact the law is having on our country." 

Supporters of the law hope that as more people gain coverage, the political fight over health care will fade. President Barack Obama won a legal victory in late June as the Supreme Court ruled federal subsidies for health insurance should be allowed in every state. But Republicans gearing up their 2016 campaigns continue to argue that the law damages the economy.

"Democrats are going to take this as one of the great achievements since Franklin Roosevelt," said Robert Blendon, senior associate dean for policy translation and leadership development at Harvard University. "Every time more people are signed up, they're going to talk about it. As we see a larger share of people covered, the more the Democratic story about the law will have a positive play to their campaigns."

Republican voters, on the other hand, still oppose the law, Blendon said, and GOP candidates will argue that the law is "too costly for middle-income Americans whose incomes aren't growing and it's affecting employment."

The midyear report echoes findings that looked at shorter time periods. Last month, Gallup reported that the number of people without insurance in the second quarter of the year fell to 11.4 percent, its lowest point since Gallup began tracking coverage in early 2008.  Gallup and Healthways ask 500 U.S. adults each day whether they have health insurance.

As of midyear, Rhode Island had the lowest uninsured rate nationwide, with less than 3 percent of residents lacking coverage, Gallup found. States led by critics of the law tend to have higher uninsured rates. In Texas, nearly 21 percent of people aren't covered.

States that helped implement the law saw the biggest increases in coverage. States that both expanded Medicaid, the federal-state program for the low-income, and built their own health insurance enrollment websites made the most progress, the Gallup midyear report found, mirroring similar findings over the past year.

The health law allows states to expand Medicaid for people with income up to 38 percent above the federal poverty level. So far, 30 states and the District of Columbia have expanded Medicaid.

Arkansas, Kentucky, Oregon, Rhode Island, and Washington all saw drops in the uninsured rate of more than 10 percentage points from 2013 to the first half of 2015. In Arkansas, the share of residents without coverage fell from 22.5 percent to 9.1 percent—a 13.4 point decrease.

While seven of the 10 states that saw the biggest improvements in coverage rates broadened Medicaid eligibility and constructed their own health insurance exchange websites, Mississippi did neither. Mississippi's uninsured rate fell from 22.4 percent of residents to 14.2 percent.

Among the 10 states with the largest changes, North Dakota relied on the federal website to enroll its residents but expanded Medicaid. Alaska also used instead of building its own exchange but recently adopted the Medicaid expansion.

The Gallup data precede an upcoming spate of releases about health enrollment statistics. This week, the federal government is likely to release new enrollment data from the new health insurance exchanges created by the health care law. The Centers for Disease Control and Prevention also is expected to release separate data about the percentage of people who had coverage earlier this year.

Supporters of the law hope the drumbeat of news about health coverage gains will give them a chance to restate their argument about the 2010 law's benefits and ultimately will translate into a more positive political narrative.

However, public opinion has inched up only slightly. About 47 percent of Americans approved of the law in a Gallup poll based on 2,013 respondents conducted between July 1 and July 5, right after the Supreme Court decision in King v. Burwell. That's a more positive view than late last year, when 56 percent of people disapproved of the law and 37 percent backed it. But Gallup surveys since early 2013 have never shown that a majority of people support the law.

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Nearly 944,000 Obamacare Sign-Ups Through Special Enrollment

By Melissa Attias, CQ Roll Call

August 13, 2015 -- Almost 944,000 people in the 37 states that use signed up for coverage between the close of the official enrollment period in February and the end of June because they qualified through special circumstances, according to federal data released last week.

While most of the focus has been on the number of sign-ups during the health law's first two open enrollment periods, the data shows the growing importance of enrollment outside of those official windows—particularly as awareness of those opportunities grow. Changes such as a loss of other health insurance, a divorce or marriage, a change in family size or a move are among the other pathways to coverage during other times of the year.

"Life changes are often impossible to predict, but access to affordable and quality health care coverage should never be," Kevin Counihan, CEO of the Health Insurance Marketplace, said in a statement.

The number of people taking advantage of the special enrollment is substantial, but only a fraction of the number of people who may be eligible because they recently lost jobs or faced other changes, said Larry Levitt, Senior Advisor to the President at the nonpartisan Kaiser Family Foundation, a health policy research organization. 

"When people lose their jobs and health benefits, their hope is often that unemployment will be only temporary so they may not go immediately to the marketplace to sign up for health coverage," he said.

The Centers for Medicare and Medicaid Services (CMS) figures only illustrate how many people with special circumstances chose a plan through the federal exchange website from February 23 to June 30. The information does not say how many individuals paid their premiums and remained insured. The number of people enrolled in health plans sold in both state and federal insurance markets fell from 11.7 million near the end of February to 10.2 million customers who had paid their premiums at the end of March, according to the Department of Health and Human Services.

Of the roughly 944,000 people who used a special enrollment period to choose coverage on, 50 percent resulted from the loss of qualified health coverage, 19 percent from being found ineligible for Medicaid or the Children's Health Insurance Program (CHIP), 15 percent during a grace period for people who owed taxes because they weren't covered last year and 16 percent for other reasons.

The number of people signing up through special circumstances ballooned during tax-filing season. The agency reported that the people using this route increased from an average of more than 5,000 a day before March 15 to more than 38,000 on April 30, the last day of the tax special enrollment period for people who paid tax fines because they weren't covered. From May 1 to June 30, health plan selections through special enrollment fell again to an average of more than 6,000 a day.

People who enrolled during special enrollment were younger than those choosing plans during the regular open enrollment window. The CMS suggests that the exchange is "providing valuable continuity in coverage for younger consumers as they transition between jobs, move off their parent's health insurance plan, or experience other life changes, such as getting married or the birth of a child."

The report says more than 180,000 people chose plans through special enrollment after they were determined ineligible for Medicaid or CHIP. But technical troubles with are currently preventing people who no longer qualify for Medicaid and may be eligible for special enrollment to enroll through the federal website. Instead, those people have to sign up by phone or other avenues.

"Consumers trying to enroll in coverage through one particular special enrollment period are experiencing issues at this time and are unable to complete their application," Health and Human Services Department spokesman Ben Wakana said in an email. "We are making sure that these individuals know that they are in fact eligible for marketplace coverage and providing the help and support consumers need."

The next open enrollment period for coverage through the exchanges set up under the health care law begins Nov. 1 for coverage beginning in January.

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Changes Needed to Health Law, Says Urban Institute Report

By Sahir Doshi, CQ Roll Call

August 11, 2015 -- The Urban Institute, advised by former White House health officials, recommended Tuesday that the Centers for Medicare and Medicaid Services allow states to partially expand Medicaid by covering people with income up to the federal poverty line, rather than 38 percent above the poverty line.

The suggestion was one of several in a report that described ways to improve the Affordable Care Act. The report was noteworthy not only because it occasionally strayed from Obama administration positions and contained implicit criticism of the law but also because it provided a glimpse of what some Democrats would do to change the law if they could.

Democrats won't have the opportunity to revise the law in the next year, given Republicans' control of Congress. Even if Democrats controlled Congress and the presidency, the cost of the proposals—$453 billion to $559 billion over 10 years—would make it challenging to get enacted. A few of the recommendations could be implemented by executive action, though, without the need for Congress to pass new legislation.

Former administration officials who reviewed the report included Liz Fowler and Chris Jennings.

Among the recommendations were proposals to:

  • Enhance the premium tax credits and cost-sharing reductions for people who buy health insurance through the health care law's new marketplaces. The revised premiums would reduce the amount that individuals would have to pay as a percentage of their and expand the cost-sharing subsidies that pay for patients' out-of-pocket costs to people with income up to three times the federal poverty limit, rather than 2.5 times the poverty limit. Subsidies would be linked to gold-level plans, which cover about 80 percent of medical costs, rather than the silver plans, which pay for about 70 percent of costs.
  • Expand benefits for workers' families who were affected by the so-called "family glitch." The organization wants the IRS to change its interpretation. 
  • Increase federal grants for IT development and operations; consumer outreach and enrollment activities; and the enforcement of regulations.

The Urban researchers recommended paying for the proposal by, among other things, increasing the Medicare payroll tax on wages, extending Medicaid drug rebates to Medicare, boosting cigarette and alcohol taxes, and replacing the so-called Cadillac excise tax for high-cost health insurance plans with a cap on the tax exclusion for contributions to employer-based health insurance.

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Children's Health Advocates Watch for Overdue Marketplace Analysis

By Marissa Evans, CQ Roll Call

August 14, 2015 -- Funding for the Children's Health Insurance Program (CHIP) expires in two years, and most health policy experts say that private insurance plans in the new health care law marketplaces don't come close to offering comparable benefits for children. The Department of Health and Human Services (HHS), which oversees the marketplace plans, was supposed to compare the coverage in a report that was due April 1.

The overdue analysis is likely to significantly influence the debate over whether the states' CHIP coverage should continue beyond 2017. More than 8 million children could be affected.

The report could put the administration in the politically awkward position of finding that coverage in the health care law marketplaces—which  President Barack Obama made a centerpiece of his domestic policy agenda—offers insurance that is not as beneficial for children currently receiving CHIP coverage.

HHS officials declined to explain the delay.

"At this time, we do not have an update on the report," according to an email statement from an HHS official.

CHIP was implemented in 1997 to provide health coverage to children in families earning between 200 percent and 300 percent of the federal poverty level—too much money to qualify for Medicaid but typically not enough to afford private insurance plans. Before the Affordable Care Act, Medicaid typically covered families making up to 100 percent of the federal poverty line. In 2013, 8.1 million kids were covered under CHIP at a cost of $13 billion.

Congress reauthorized funding for the program until 2017 but the report was supposed to give some indication on where insurance coverage for kids stands now.
Lawmakers criticized the delay.

"Sen. Alexander is disappointed that the administration has failed to meet the explicit requirement established in the President's health care law and release this study—now more than 4 months overdue—so that Americans will know how plans on the Obamacare exchange are serving our children who need help the most," according to an aide for Alexander in an email statement.

Even though funding expires in 2017, children's advocates and CHIP program directors are already working to find solutions to make sure the plans in the exchange would be comparable for CHIP beneficiaries.

Trish Riley, executive director for the National Academy for State Health Policy said that policymakers should not wait for the report to explore solutions aimed at ensuring that private commercial insurance plans are as extensive as CHIP and Medicaid plans for pediatric coverage. The group is planning to convene a study group of policy analysts this fall to tackle the issue.

"The bigger question is less about this report then how do we take lessons of CHIP and make commercial policies work," Riley said.

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Shortcut for Budget Reconciliation Mulled by GOP Leaders

By Paul M. Krawzak, CQ Roll Call

August 11, 2015 -- GOP leaders are considering an abbreviated form of the powerful budget reconciliation process this year, giving them the leeway to focus on other pressing matters while still issuing a prod to the president on the health care law.

Under the approach being discussed, the Senate would act on a House-written reconciliation bill to overturn the health care law, rather than going through the laborious steps it would take to write and debate its own measure.

An accelerated reconciliation schedule would take less time away from what lawmakers say are essential laws they must pass during an increasingly jammed legislative schedule. That includes finding a way out of an impasse over the fiscal 2016 spending bills, reviewing President Barack Obama's Iran deal, passing highway legislation, and extending tax breaks.

The GOP expects to use reconciliation to attempt a repeal of portions of the 2010 health care law. Even though Obama is almost sure to veto any repeal, many Republicans remain committed to sending a repeal to his desk and putting him on the record. Repeal remains particularly important to many in the conservative GOP base.

In general, reconciliation legislation is limited to measures that would result in changes in revenue or spending. A major challenge for Republicans is to write a reconciliation bill that would reduce the deficit, as required by the reconciliation instructions, given that the Congressional Budget Office has estimated that a full-scale repeal of the law would add to the deficit.

The House has passed numerous bills aimed at killing the Affordable Care Act but they have never gotten through the more narrowly divided Senate, where 60 votes are needed to consider most measures.

Ironically, letting the House write the reconciliation bill would be similar to the unusual tack that Democrats took when they used the expedited process to pass parts of the health care law in 2010. Contrary to the usual practice, the Senate skipped writing its own reconciliation bill and instead relied on a House bill. Reconciliation allows budget-related legislation to pass in the Senate with a simple majority.

Favorable Reactions

No GOP leader has confirmed a plan to let the House go first, but some high-ranking Republicans have spoken favorably of the idea.

"I certainly wouldn't rule that out," Senate Republican Conference Chairman John Thune of South Dakota said. "I would certainly be open to it only because, like I said, I think that anything that can help expedite our ability to process a lot of the things that we have to get done would be helpful."

GOP leaders have said little about reconciliation since the Senate completed adoption of the fiscal 2016 budget resolution (S Con Res 11) in May, suggesting it is no longer the priority it once was. It's even possible Republicans will put off reconciliation until next year, when there may be more time for it.

Republican senators said any House-written bill would have to be acceptable to them and also drawn to comply with the Byrd rule, named for the late Sen. Robert C.  Byrd, D-W.Va., which imposes complex limits on reconciliation in the Senate. "If we work it out between the houses and if it's a way to get it done more effectively, that sounds like a good idea," Senate Majority Whip John Cornyn, R-Texas, said. "But I haven't heard any plan announced." 

House Ways and Means Chairman Paul D. Ryan, R-Wis., said last month that one of his challenges in writing a reconciliation bill is to make sure it complies with Senate restrictions.

Best Odds

Utah Republican Sen. Mike Lee, who is pushing to use reconciliation to repeal as much of the health care law as possible, supports any procedure that would work, including letting the House write the bill.

"That does give us the best odds of getting something to the president's desk," Lee's spokesman Conn Carroll said. "I think that is the understanding of what is the best way to go about it." Lee and Senate Majority Leader Mitch McConnell, R-Ky., put out a joint statement last month pledging to use reconciliation to send a repeal bill to the president.

Senate Homeland Security Chairman Ron Johnson, who sits on the Budget Committee, said it would be all right with him. "We'll see how the thing works out but I have no problem with the House sending something over to us," the Wisconsin Republican said.

Nevertheless, leaving the Senate out of this part of the reconciliation process would break with the usual practice, in which both chambers write and pass their own reconciliation bills before agreeing on common legislation in a conference committee.

The reconciliation instructions in the fiscal 2016 budget resolution direct the Senate Finance and the Health, Education, Labor, and Pensions committees to report reconciliation legislation to the Senate Budget Committee, which then would package the proposals into a reconciliation bill that would go to the Senate floor.

The instructions similarly direct the House Ways and Means, Energy and Commerce, and Education and the Workforce committees to report reconciliation measures to the House Budget Committee, which would combine the proposals into a reconciliation bill.

Not Unprecedented

Though unusual, it is not unprecedented for one chamber to skip part of the process. When Democrats controlled both chambers in 2009, they wrote a budget resolution instructing two authorizing committees in the Senate and three in the House to report reconciliation legislation to their respective budget committees.

While the House committees reported, the Senate committees did not, and the Senate never wrote its own reconciliation bill. The House Budget Committee wrote a reconciliation bill early in 2010, and the House passed it. The Senate then took up the House bill, made minor changes, and sent it back to the House. The House cleared the bill for Obama's signature.

Apart from that instance, the House and Senate have almost always written and passed their own reconciliation bills and then gone to conference.

Jim Dyer, a principal at the Podesta Group and former staff director and clerk of the House Appropriations Committee, said it may be that neither party wants to spend much time on a debate over repeal.

"I don't think anybody is under any illusions about any level of success here," he said. "So you end up saying to yourself, 'Well, if you did this exercise—and it is time-consuming—but if you did this exercise what are you going to get out of it?'"

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