“The Affordable Care Act may be the law of the land, but some states are still doing their best to avoid it. Nearly half the states have refused to participate in the law’s expansion of Medicaid. Some describe this reluctance as tantamount to a moral crime—see Virginia Governor Terry McAuliffe’s recent statement that expansion’s opponents are “prevent[ing] their own constituents from getting access to health care.”
As a doctor, I know this isn’t true. Medicaid is sold to the public as a magic pill that will solve the poor’s inadequate access to medical care. But reality isn’t so simple.
Simply put, Medicaid gives patients terrible access to medical care. A recent study found that nearly a third of doctors no longer accept new Medicaid patients. In some states, as many as 60 percent don’t. Why not? Because Medicaid operates in a world without economic logic.
Bureaucrats in Washington dictate how much money doctors receive for the treatments and services they provide. Unfortunately, on average they reimburse at less than the actual cost—the average Medicaid reimbursement is 40 percent less than the reimbursement from private insurance.
Medicaid payments don’t even match the reimbursement rates for Medicare. Primary care receives 59 cents for every Medicare dollar. Obstetric care receives 78 cents. Overall, Medicaid receives 66 cents for every Medicare dollar—a one third cut for the exact same service.”

“The price tag for healthcare.gov, the Obamacare website, is approaching $1 billion even as key features remain incomplete, congressional auditors said.
The budget to get the site ready for the next round of enrollments, starting in November, jumped to $840 million as of March, according to the Government Accountability Office. That’s a $163 million increase since December.
Accenture Plc (ACN), the company that took over building the site that failed at its introduction this past October, is expected to be paid $175 million as of June, an $84 million increase from the estimate in January when it signed a contract. The data are part of testimony for a congressional hearing today in the Republican-led House. The GAO places blame for the site’s rising price on poor planning and supervision of contractors who built the federal health exchange.
If the management doesn’t improve “significant risks remain that upcoming open enrollment periods could encounter challenges,” William Woods, the GAO’s director of acquisition and sourcing management, is scheduled to testify according to prepared remarks released by the Energy and Commerce Committee.”

“The recent decision of a three-judge panel in the Halbig case, if it prevails, would have a direct effect on the availability of subsidies under the Affordable Care Act (ACA). People buying coverage on their own in insurance exchanges run by the federal government would be ineligible for income-based subsidies. Depending on how you count, that would take premium subsidies away from 4.6 million people in 34 states, or 4.7 million people in 36 states if you count New Mexico and Idaho (which have signaled their intention to operate their own exchanges but are still using the federal marketplace).
Many more people are eligible for subsidies but haven’t yet signed up. We estimate (using the approach described here that a total of 9.5 million uninsured people are eligible for subsidies in federal marketplace states (or, 9.7 million people if you include New Mexico and Idaho).
Since many low and moderate income people would have difficulty affording insurance without the subsidies, this would no doubt alter the extent to which the ACA is reducing the number of Americans who are uninsured, which recent surveys peg at about 8 to 10 million.
But, there would also be two important side effects of the Halbig case.”

“Luis Martinez of Hialeah survived two heart attacks during the more than 10 years that he went without health insurance.
So he was relieved to finally find coverage on the Affordable Care Act’s insurance exchange in March, two weeks before the enrollment deadline.
But four months after he and his wife signed up for a subsidized, bronze-level health plan with Coventry, Martinez, 51, said he feels as though he has fallen into a black hole of government bureaucracy while trying to prove his income and his wife’s citizenship in order to keep their coverage, part of a national effort to verify policyholders’ eligibility.
Martinez, who has stents implanted in his coronary arteries, said he has tried repeatedly for more than a month to comply with the government’s requests for additional documentation to resolve inconsistencies in his personal information — or risk losing his $457 monthly subsidy, and health insurance for him and his wife, Rocio Balbin, 46.
So far, officials with the U.S. Department of Health and Human Services are not satisfied with his response.”

“New Mexico decided Friday to stick with a federal online system for another year to enroll individuals in health insurance plans.
The state’s health insurance exchange governing board voted 11-1 to continue using the federal computer system for determining eligibility and to enroll individuals starting in November when the next open enrollment begins.
A majority of board members worried that New Mexico wasn’t ready to switch to a state-run online system for individuals. Any technical failures could delay enrollment and discourage consumers from trying to obtain health coverage, they said.
Continuing with the federal system for another year is the “safest, most risk-free” way of enrolling New Mexicans, New Mexico Health Connections CEO Martin Hickey said.”

“States running their own Obamacare exchanges were supposed to wean themselves off federal funding by the end of this year, but some of them want that Obama administration spigot open a bit longer.
The states aren’t asking for the feds to dole out more money on top of the $4.6 billion already dedicated to exchange planning and construction. But they do want to be able to spend their federal exchange grants into 2015 as they grapple with core components of the insurance portals that are balky, unfinished or in disrepair.
The viability of state exchanges became more urgent this week after conflicting court rulings created uncertainty about whether Affordable Care Act subsidies would be available through the federal exchange — or whether the state market would be the only legal route.
A POLITICO survey of the 15 state-run exchanges (including Washington, D.C.) found that 11 are thinking about using federal dollars in 2015 — and four of those states have already applied.”

“Nancy Pippenger and Marcia Perez live 2,000 miles apart but have the same complaint: Doctors who treated them last year won’t take their insurance now, even though they haven’t changed insurers.
“They said, ‘We take the old plan, but not the new one,’” says Perez, an attorney in Palo Alto, Calif.
In Plymouth, Ind., Pippenger got similar news from her longtime orthopedic surgeon, so she shelled out $300 from her own pocket to see him.
Both women unwittingly bought policies with limited networks of doctors and hospitals that provide little or no payment for care outside those networks. Such plans existed before the health law, but they’ve triggered a backlash as millions start to use the coverage they signed up for this year through the new federal and state marketplaces. The policies’ limitations have come as a surprise to some enrollees used to broader job-based coverage or to plans they held before the law took effect.
“It’s totally different,” said Pippenger, 57, whose new Anthem Blue Cross plan doesn’t pay for any care outside its network, although the job-based Anthem plan she had last year did cover some of those costs. “To try to find a doctor, I’m very limited. There aren’t a lot of names that pop up.””

“The decision in the Halbig v. Burwell case this week was an unexpected legal boon to opponents of Obamacare. Spearheaded by the Cato Institute’s Michael Cannon and law professor Jonathan Adler, the case will almost certainly lead this debate about the text of the Affordable Care Act back to the Supreme Court. My colleague Sean Davis has written a comprehensive piece on the case, particularly on the nature of the supposed “drafting error” at its core.
But whatever the ultimate outcome for Halbig, the case serves as a reminder of the uneven ground on which Obama’s health care law is likely to be standing over the next two years. Whether facing challenges in the courts, or in implementation, as we saw in the GAO’s security report this week, or simply as a matter of political approval, Obamacare is going to be a subject of uncertainty in 2016, and its survival will depend on who wins the election, as I wrote here last month.
This raises an interesting question about how the presidential candidates will interact with the law. The law’s continued instability and problems will have to be answered – but the odd circumstance likely to result from the political frame of the issue is that Republicans will put forward a plan to replace Obamacare, but Democrats won’t.
One of the lazier memes of Democratic politicians and a few too many members of the media over the past several years has been the myth that Republicans have no alternative to Obamacare. This is the sort of thing that doesn’t pass even the most basic assessment of accuracy in reporting – here is a list of the health care reforms introduced by Republican House members in 2012, and here’s one for 2013. While their plans vary in scope, there are eight things Republicans generally agree about when it comes to health care reform:
•They want to end the tax bias in favor of employer-sponsored health insurance to create full portability, either through a tax credit, deductibility, or another method;
•They want to incentivize the reform of medical malpractice laws, likely through carrot incentives to the states;
•They want to allow for insurance purchases across state lines;
•They want to support state-level pre-existing condition pools;
•They want to fully block grant Medicaid;
•They want to shift Medicare to premium support;
•They want to speed up the FDA device and drug approval process; and
•They want to maximize the consumer driven health insurance model, making high deductible + health savings account plans larger and more attractive.”

“MIAMI (AP) — Linda Close was grateful to learn she qualified for a sizable subsidy to help pay for her health insurance under the new federal law. But in the process of signing up for a plan, Close said her HealthCare.gov account showed several different subsidy amounts, varying as much as $180 per month.
Close, a South Florida retail worker in her 60’s, said she got different amounts even though the personal information she entered remained the same. The Associated Press has reviewed Close’s various subsidy amounts and dates to verify the information, but she asked that her financial information and medical history not be published for privacy reasons.
“I am the kind of person the Affordable Care Act was written for: older, with a pre-existing (condition) and my previous plan was being cancelled. I need it and I’m low income,” said Close, who has spent more than six months appealing her case. “The government pledged to me that original tax credit amount. It’s crazy.”

“A lot of attention is being paid to the dueling decisions in two U.S. appeals courts about whether the U.S. government can provide tax credits to people in federal- as well as state-run insurance exchanges. In human terms, the stakes are high: Millions of moderate-income people will not be able to afford health coverage without a subsidy, and a court ruling could gut coverage expansion in the 36 states with federally run insurance exchanges, unless states decide to set up their own exchanges. One of the cases, Halbig v. Burwell, also adds uncertainty to the enrollment process set to begin this fall, when millions more people are expecting to get tax credits–and wondering if they may be taken away.
Amid the reaction, little attention has been paid to whether Americans will perceive Halbig as a legitimate legal question or as more inside-Washington politics. The plaintiffs paint this as a case about statutory language and intent. The health-care law said that tax credits would be provided only in state-run exchanges, they argue, and it is executive overreach to provide credits in federal exchanges. Proponents of the Affordable Care Act see this as a thinly veiled game of gotcha being played over imperfect legislative language despite clear legislative intent. They believe that providing tax credits in the exchanges was always a central element of the Affordable Care Act’s strategy to expand coverage whether in state or federal exchanges–and that everybody knows it.”