By Marissa Evans, CQ Roll Call

November 9, 2015 -- The folks who run the health insurance marketplace, or exchange, in Massachusetts are using tax records to identify state residents who could benefit from, but haven't yet signed up for, coverage under the federal health care law.

In California, exchange officials are touring the state in a bus to sign up uncovered Californians. 

As the 2010 federal health care law's  third open enrollment season got underway this month, many of the states that have established health insurance exchanges under the law say they are trying new approaches to sign up members of hard to reach populations such as minority groups and non-English speaking communities. 

Reaching those populations is no small challenge; a Kaiser Family Foundation study released in October found there are still 15.7 million uninsured people in the U.S. who could qualify for financial assistance with premiums if they applied.

Trish Riley, executive director for the National Academy of State Health Policy, said that state exchanges—established in 16 states and the District of Columbia—are in a refining period with revamping outreach beyond fliers and word of mouth. 

"They have to balance the day to day operation of the exchange and the benefits of their outreach and community work," Riley said.  

Tax Credits

During the first two open enrollment periods, the number of Minnesotans receiving tax credits to help them offset the costs of health insurance premiums, as well as the value of tax credits they received, were lower than national average.

This year, with premiums for some policies expected to jump by as much as 49 percent, MNsure, the Minnesota health insurance exchange website, will include more information to make consumers more aware of the credits, said Shane Delaney, the exchange's director of communications and marketing. 

"We're trying to tell consumers, 'yes these premium increases are out there but there's this solution called MNsure that you can use,'" Delaney said. "The discussions about the tax credits are going to be a driver to our site."

Besides letting users know financial help is available, MNsure is also adding tools to help consumers pre-shop for insurance, including a widget that will rank plans best-suited for them based on information they provide such as how often they go to the doctor, their age, and where they live.

Covered California, while long lauded as a model state exchange for its high enrollment numbers and outreach strategies, is also hunkering down for the open enrollment period. Aside from a statewide bus tour to help residents sign-up for insurance, exchange officials are also focused on spotlighting the subsidies available. 

It's about making sure they see what the bottom line is without having to do the math, according to Covered California spokesman James Scullary.

"Many California residents are still not aware of all the elements," of the health care law, Scullary said. "One of them is the subsidies available."

Louis Gutierrez, executive director at Massachusetts Health Connector, said that the exchange is focused on the remaining uninsured population. 

Prior to the federal health law, Massachusetts had its own statewide insurance mandate for residents, pushing its insured population rate up to 96 percent. Gutierrez said the goal now is to focus outreach in underrepresented communities. Using tax filing information, the Massachusetts Department of Revenue mailed Connector information to roughly 120,000 uninsured residents. 

More Hours

On top of that, the Connector is adding an additional 200 call center hours to help consumers sign up for insurance. Officials also added four new walk-in centers, as well as an ombudsman to help with user complaints. The site also added a plan comparison tool and a provider search function.

Gutierrez said what struck him most during focus group sessions was the disbelief people had when realizing they could afford health insurance. 

"There's a prevailing assumption [among consumers] 'well of course this has to be too expensive,'" Gutierrez said. "But when you put existing examples in front of them and they see what premium prices are with subsidies there's this fascinating head turn and they say 'huh this could be made to happen.'"

Among the states without exchanges, it's up to consumers to find help on Healthcare.gov or a local community organization that is helping with enrollment efforts.

In March 2014, the Republican-led Arkansas legislature went as far as enacting a law that prevents the state's Insurance Department from using state funds to promote or provide information about the federal health law.

Even in non-exchange states without such laws, many health department websites have little to no information for consumers about where to find help.

National organizations like Enroll America are increasing efforts for the open enrollment period, in those states. The organization said in an October news release that it will increase staff, especially in Alabama, Illinois and South Carolina. The organization works with a coalition of more than 6,000 local community partners.

"Our goal in year three is to identify the remaining obstacles for consumers to enroll in or renew their coverage, and take action to address those challenges," said the organization's president, Anne Filipic.

By Marissa Evans, CQ Roll Call

November 9, 2015 -- Like the U.S. overall, Texas saw a decline in the number of children without health insurance in 2014. But supporters of the federal health care law say hostility to the Affordable Care Act is preventing the state—which still has the nation's biggest population of uninsured kids—from making faster progress.

The number of uninsured children in Texas fell by 11.7 percent to about 784,000 in 2014, down from around 888,000 in 2013, according to a Georgetown University Center for Children and Families report released in October.

Nationwide, the number of uninsured children fell more than 15 percent, from 5.2 million in 2013 to 4.4 million in 2014, the study found, using data from the Census Bureau's American Community Survey.

In measuring that population in 2014, the study captured the impact of key provisions of the 2010 health care law during their initial year, including the expansion of Medicaid in many states and the creation of state and federal health insurance exchanges that allow Americans to compare coverage options and sign up for federal subsidies to make premiums more affordable.

The Georgetown study found that states that expanded Medicaid under the health care law added twice as many children to insurance rolls. In those states, the rate of uninsured children fell by 21.7 percent in 2014 while states that did not expand Medicaid only saw an 11.6 percent decrease.

In Texas, two successive Republican governors and the GOP-controlled legislature declined to expand Medicaid or establish a state insurance exchange. And there's no sign of  movement toward either option.

"Governor Abbott believes that expanding a program that is bad for patients, doctors, and taxpayers is no way to solve our health care issues," said John Wittman, Gov. Greg Abbott's deputy press secretary. "Texas should be able to address our unique health care situation without federal interference, putting patients and doctors in charge of health care decisions."

Even if Texas doesn't expand Medicaid, it should at least improve efforts to help more citizens obtain coverage in the federal marketplace or through Medicaid or the Children's Health Insurance Program (CHIP), says Anne Dunkelberg, an associate director at the Center for Public Policy Priorities, a nonpartisan research organization based in the state capital, Austin.

"We're missing this opportunity in Texas and I think the data clearly shows that getting parents enrolled in insurance is very important," Dunkelberg says. "The legislature and elected officials have been a really big gatekeeper of these efforts."

Dunkelberg says state legislators don't understand how their resistance to the federal health law is preventing Texas children from getting coverage.

"The fact that it's so caught up in political struggles is a source of frustration," she says. "It doesn't make sense necessarily that this would be an ideologically fraught issue."

But even with the third year of open enrollment underway, educating consumers in Texas about health insurance is especially difficult, Dunkelberg says.

In 2013, Abbott signed into law a bill requiring navigators who assist people with the online insurance marketplaces to register with the state, submit to background checks and complete 40 hours of state training on top of the 20 to 30 hours required by the federal government.

In response to public comments in 2014, the Texas Department of Insurance issued revised rules that reduced state training to 20 hours, but set fees ranging from $100 to $400. According to Texas' registry list, there are 501 navigators throughout the state. 

Such rules are a hurdle to expanding access to insurance to disadvantaged Texans, says Jill Ramirez, executive director for the Latino HealthCare Forum, a Texas-based nonprofit.

"My day is spent getting people to be able to trust us enough to get them enrolled and letting other people know they can do the same," Ramirez says.

Hispanic adults are at the highest risk of being uninsured in the U.S., with more than one in four lacking coverage, according to a Kaiser Family Foundation report. The Latino HealthCare Forum has been keen on dispatching volunteers to schools, malls, recreation centers, parks, churches and anywhere else in the Eastern Crescent community of Austin to connect with potential enrollees. Ramirez says a lot of the residents may not speak English or understand that they qualify for help.

Mixed-status immigrant families also may assume no one in their family is qualified for health insurance, even though children can qualify for Medicaid and CHIP, she says.

"There's still a lot of fear in terms of believing that if you're mixed immigration you can still apply for your children," Ramirez says. "We have to do a lot of education about that issue letting people know that if you have a mixed immigration household that the government isn't going to come after you for signing up."

By Kerry Young, CQ Roll Call

November 9, 2015 -- A key health policy goal of the new Ways and Means chairman—changes to the treatment of people recovering from serious illnesses, injuries, and surgeries—is moving forward in an influential advisory panel. The work ultimately could result in an overhaul of one of Medicare's fastest-growing expenses. 

An overhaul of so-called post-acute care, a roughly $60 billion annual expense for Medicare, has been a top priority for Rep. Kevin Brady, R-Texas, and has the support of the Obama administration. Medicare's spending on post-acute care more than doubled between 2001 and 2012, with different payment rates set for the four main settings for this treatment. Lawmakers are looking for ways to better direct people toward the best sites for post-acute care, while also keeping this spending in check by flattening payments. Decisions about post-care settings now often are based on factors such as a hospital's relationship with a particular center, according to the Medicare Payment Advisory Commission.

MedPAC staff on Nov. 6 said it would be possible to develop a "reasonably accurate" unified payment system for post-acute care, but noted there are some thorny issues to resolve. Lawmakers have been looking for MedPAC's guidance in this effort. The IMPACT Act (PL 113-85), which Brady helped passed last year, ordered MedPAC to provide Congress with a report by June 2016 on creating a new unified payment for post-acute payment.

Among the ideas being considered for the report is whether to create new coordinating agencies that would work to direct patients into the best rehabilitation settings for them. These navigators could stand to profit, or lose money, based on how well patients fare.

The transition from hospital to post-acute settings now is often stressful and chaotic. Frail people recovering from strokes and other serious illnesses and their family members often are confused and frustrated while attempting to sort out different options for recovery care.

Craig Sammit, chief clinical officer at insurer Anthem Inc. and a MedPAC member, objected to the idea of bringing in a new third-party to coordinate care, saying it would add another "layer of complexity" to these cases. Instead, Medicare should be looking to bolster the ability of primary-care doctors to guide their patients through recoveries, or to rely on accountable care organizations more for this work, he said.

"I am not comfortable with the creation of yet another layer," Sammit said. "I don't think we have given enough opportunity to see that the layers that currently exist, when held accountable, can manage this."

Other panel members concurred with his view that adding coordinators would add complexity to a field of care that leaves many patients and their families bewildered.

Still, MedPAC Executive Director Mark E. Miller said there appears to be a need for navigators of some kind for post-acute care, although how this role is filled may not be clear yet.

"You are at once saying 'I need coordination. It's the most concerning thing that any family talks about.' And I hear this all of time, too," Miller said, summarizing the discussion. "But you don't want anybody to enter the picture."

The coordinator approach had been proposed by Rep. David McKinley, R-W.Va., in his bill (HR 1458), for which he has three cosponsors.

MedPAC and Congress have given themselves a long time-frame for addressing payments for post-acute care. While serving as chairman of the Ways and Means health subcommittee, Brady last year pushed for the IMPACT Act (PL 113–185) that requires the different providers of post-acute care to use a uniform tool to judge how well people fare in the different care settings. That would put a new PAC payment system in place by 2023 at the earliest, by MedPAC's estimate.

But Congress and Medicare officials could accelerate that schedule. In an interview last week with CQ RollCall, Brady outlined an ambitious goal for pressing ahead on Medicare legislation in the year ahead, even with the inevitable tensions surrounding the 2016 elections likely to disrupt much of the work of Congress.

"I am hopeful that we can move a package of hospital reforms, including post-acute reforms and a number of bipartisan health care priorities here over the next six months," Brady said.

The Obama administration also is seeking an overhaul of post-acute care. It estimated in its fiscal 2016 budget request that $9.6 billion could be saved over a decade from the creation of a bundled payment.

By Kerry Young, CQ Roll Call

November 13, 2015 -- Hospital groups are asking Medicare officials to delay the start of a program that will hold some of them accountable for how well their elderly and disabled patients fare after hip and knee replacements.

Many hospital associations have expressed support in general for the aim of the Centers for Medicare and Medicaid Services' (CMS) so-called Comprehensive Care for Joint Replacement test model. The agency in July unveiled the draft rule for this program, which is designed to pay hospitals in about 75 U.S. regions more if their patients fare well after hip and knee replacements.

Hospital with poor results would have to return to Medicare a portion of the payment for these procedures.

CMS is expected to release the final version of this rule within days. The agency proposed beginning the test program on Jan. 1, 2016, and ending it Dec. 31, 2020.

The American Hospital Association asked CMS that the start date be pushed to July 1, 2016. The Greater New York Hospital Association asked for a delay to 2017. "If the delay can't be that long, CMS should at least wait until Oct. 1, 2016 to begin the program," wrote Kenneth E. Raske, president of the association, which represents more than 160 member hospitals and health systems in New York, New Jersey, Connecticut, and Rhode Island.

The stakes are high for many hospitals. Hip and knee replacements are some of the most common surgeries performed on people enrolled in Medicare. The program spent more than $7 billion for hospital care associated with these procedures in 2013, with more than 400,000 cases covered, according to CMS.

In his Sept. 8 letter to the agency, Raske of the Greater New York Hospital Association said that CMS had been expected to issue this hospital rule around Nov. 1.

With a mere 60-day notice, it would be impossible for hospitals to develop and implement a meaningful program, he said.

Raske pointed out that hospitals in his group had taken from six months to a year to prepare to participate in another major CMS test program, known as the Bundled Payments for Care Improvement initiative.

Other groups supporting a delay in implementation until at least October 2016 include the Association of American Medical Colleges, Michigan's Trinity Health, and the University of Pittsburgh Medical Center.

In the final rule, CMS also will address other issues raised in the comments about the program. Stryker, a leading maker of orthopedics, asked CMS to consider expanding participation in this program beyond hospitals to so-called conveners that can partner with hospitals. The Kalamazoo, Michigan-based firm said its experience in consulting with hospitals indicates it could help in the efforts to achieve savings through the new Comprehensive Care for Joint Replacement (CCJR) program. Stryker noted in a comment to CMS that it already is a partner in the Bundled Payments for Care Improvement initiative.

"Stryker believes there is ample evidence that conveners play a critical role in bundled payment initiatives, and they therefore should be encouraged to play an active role in the CCJR Model to ensure the success of the program," the company said.

If CMS doesn't broaden the rules of participation for the hip and knee replacement test, the agency should delay the start of this program until Oct. 1, 2016, which is also the start of Medicare's fiscal year 2017 payment period for hospitals," Stryker said. "This would provide hospitals the necessary time to analyze data, redesign care, and put in place proper agreements with partners such as Stryker to prepare for the new program," the company said.

By Jad Chamseddine, CQ Roll Call

November 12, 2015 -- The American Medical Association (AMA) is pushing the Department of Justice (DOJ) to block two health insurance mega-mergers, arguing that merely forcing the companies to sell off assets won't prevent price increases.

The country's largest association of physicians has previously been hostile to Aetna Inc.'s acquisition of Humana Inc., and Anthem Inc.'s purchase of and Cigna Corp. But in a letter made public on Wednesday, the group said "any remedy short of blocking the mergers would not adequately protect consumers," suggesting the government should not settle for just divestitures.

The AMA said the increased size of the health care insurance companies would give them too much power and result in physicians being reimbursed at "below competitive levels," which can affect the care patients receive.

"Physicians may be forced to spend less time with patients to meet practice expenses," the AMA said.  "They also may be hindered in their ability to invest in new equipment, technology, training, staff, and other practice infrastructure that could improve the access to and quality of patient care."

The association previously appeared before antitrust panels in the House and Senate Judiciary committees to warn about the deals' risks to competition.

Proponents of the merger, including the merging companies, vow that synergies created by the mergers would lead to cost cutting and further consumer benefits. The AMA questioned whether cost savings would flow to consumers, and argued that high barriers to entry would make permanent any reduction in competition resulting from the deals.

The pushback has come from various other corners, including the American Hospital Association, an organization of nearly 5,000 hospitals and health care systems that has clashed with the AMA in the past over the effect of hospital mergers on independent physicians. But the two are aligned over the insurance mega-mergers, which would reduce the number of large national health care insurance companies to three from five. Anthem would become the nation's largest, followed by UnitedHealth Group Inc., and Aetna.

The mergers have also piqued interest in Congress. Democrats showed opposition to market consolidation in hearings held by the House Judiciary and Senate Judiciary subcommittees. Several Republicans also showed concern over the deals, including Georgia Rep. Doug Collins. The Republican blamed the spate of mergers in the health care industry on the Affordable Care Act.

November 12, 2015 -- Senate Minority Leader Harry Reid on Thursday disputed GOP claims that the House-passed reconciliation bill can be rewritten in a way to repeal major portions of the 2010 health care law.

"The Parliamentarian has ruled that Obamacare cannot be repealed through reconciliation, period," a statement from the Nevada Democrat's office said. "The idea put forth by Senator McConnell's office that a so-called 'technical fix' can save Obamacare repeal in reconciliation is simply false."

Senate Parliamentarian Elizabeth MacDonough sent a memo to Senate leaders Tuesday telling them the proposed repeals of the individual and employer mandates in the health care law were a violation of the Senate's Byrd rule.

While a reconciliation bill can be passed with a simple majority, it takes 60 votes to waive a Byrd rule violation, which is likely impossible given Democratic opposition to tampering that much with the health overhaul.

MacDonough's ruling followed a meeting Nov. 6 in which Republican and Democratic staff from leadership offices and several Senate committees presented their arguments to MacDonough on the House-passed reconciliation bill (HR 3762).

The primary savings in the House reconciliation bill come from repealing requirements that individuals buy health insurance and large employers offer health insurance to their workers. The bill also would repeal other elements of the health care law including taxes on high cost health insurance plans and medical devices and a public health prevention fund.

The statement from Reid's office said even though Republicans "may be able to make narrowly tailored changes that primarily have a budgetary effect, any fix that repeals the individual or employer mandates will require 60 votes and therefore will not pass."

The Byrd rule bars what is called "extraneous matter" in reconciliation bills, including provisions where the budgetary effects are "merely incidental" to policy changes.

"Based on the Parliamentarian's ruling, the Senate reconciliation bill will have to be more supportive of Obamacare's mandates than the House-passed bill," the Reid statement said.

Donald Stewart, an aide to Senate Majority Leader Mitch McConnell, R-Ky., said Tuesday that Republicans will offer a substitute amendment that will both remove the violations of the Byrd rule and preserve the repeals in the House bill. If the substitute amendment passes muster with the parliamentarian, Republicans would be able to pass it without Democratic support as long as they lost no more than three members out of their 54-seat majority.

The Reid statement said the parliamentarian's decision "almost certainly rules out one idea currently being floated among Republicans: to repeal the mandates temporarily now and allow them to come back into effect in the future. Even this change will almost certainly require 60 votes and therefore will not happen."