Category: Implementation

Last year’s final enrollment numbers under President Barack Obama’s health care law fell just short of a target the administration had set, the government reported Friday.

The numbers are important because the insurance markets created by the president’s 2010 health care law face challenges building and maintaining enrollment. The marketplaces offer subsidized private insurance to people who don’t have access to job-based coverage.

The report from the Health and Human Services Department said about 8.8 million consumers were still signed up and paying premiums at the end of last year.

HHS Secretary Sylvia M. Burwell had set a goal of having 9.1 million customers by then.

When agencies release information on a Friday afternoon, it is generally because of unfavorable news they hope will lose potency over the weekend. On Friday, the Department of Health and Human Services (HHS) released 2015 end-of-the-year exchange enrollment data. After reviewing the numbers, it is understandable why HHS would want this release to attract as little attention as possible.

Most news stories reporting the numbers have focused on the large overall decline in exchange enrollment throughout 2015—down 25% from the number of people who selected a plan at the end of open enrollment—or how the end-of-the-year number failed to meet even HHS’ downgraded target. The most striking number from the data, however, is the large drop in exchange enrollment—equal to about 1.13 million people—during the last six months of the year. As I explain below, this large net decline is problematic for the future of the Affordable Care Act (ACA) as it likely exacerbates other adverse selection problems induced by the law.

Republican leaders of the House Energy and Commerce Committee have asked America’s Health Insurance Plans and several major insurance companies to brief staffers by next week on reinsurance payments to insurers by the Centers for Medicare and Medicaid Services.

Reps. Fred Upton (R-Mich.), Tim Murphy (R-Pa.) and Joe Pitts (R-Pa.) wrote to Marilyn Tavenner, president and CEO of AHIP, as well as Aetna, Anthem, Blue Cross Blue Shield, Cigna, Humana and UnitedHealth Group asking for briefings by March 15. The request follows an announcement made last month by CMS that it would use funds from the Department of the Treasury to make reinsurance payments to insurers, and that violates federal law, they write.

In its release of wonk beach reading late last month, the 539-page  HHS Notice of Benefit and Payment Parameters for 2017 and the 87-page 2017 Letter to Issuers in the Federally-facilitated Marketplace, the federal government displayed its latest efforts to apply science to the issue of network adequacy.  Beginning in 2018, for policies sold on healthcare.gov, the federal government will rate and display plans as “Basic,” “Standard” or “Broad.”

This network rating will be in addition to the federal government’s current efforts to ensure that networks established by an insurer are not so sparse as to be useless to the consumer. It does not appear as if states running their own exchanges will be required to do more than assess insurer networks for adequacy; state websites will not have to grade the quality of insurer networks for policies sold on their exchanges.

Most people who got tax credits to buy insurance under the federal health law will be repaying part of them for the second year in a row, according to a leading tax preparer.

H&R Block Inc. executives said Tuesday that, to date, 60% of 2015 tax filers with the credit have found that they owe the government money because they had been credited too much. That is up from 52% last year, the first year in which filers had to reckon with reporting the credit and figuring out if their income projections had been accurate.

On average, tax filers were repaying almost $580 each for excessive credits, up from $530 for overpayments during the 2014 filing year.

As of the end of the third open enrollment under the Affordable Care Act, 12.7 million people had signed up for coverage in the health insurance marketplaces, up from 11.7 million last year and 8.0 million in 2014.

Actual enrollment will end up somewhat lower than this because some people will not pay their premiums or will have their coverage terminated due to inconsistencies on their applications, and there is typically additional attrition as the year progresses (e.g., as some enrollees get jobs with health benefits).

While enrollment is in line with the HHS target announced in advance of this year’s open enrollment, it is short of earlier projections by the Congressional Budget Office, which became an implicit yardstick for judging the law. In March 2015, CBO projected average monthly marketplace enrollment of 21 million in calendar year 2016, though recently lowered that forecast to 13 million.

. . .

The Independent Payment Advisory Board, or IPAB, is one of the more notorious provisions of the Affordable Care Act because it is the perfect embodiment of belief in technocratic expertise. The IPAB’s 15 “expert” members would have great power and little accountability.

Since the law’s passage in 2010, opponents have successfully publicized the danger the IPAB poses to sensible Medicare policy and constitutional self-government, to the point that many in Congress now assume it will never go into effect. In June 2015, the House passed legislation to repeal the IPAB in its entirety.

And, yet, it is also clear that Congress’ attention is elsewhere. The slowdown in Medicare spending growth in recent years has made the IPAB less relevant – for now.

But IPAB’s demise is not a foregone conclusion, especially when Medicare spending growth accelerates again, as it almost inevitably will.

The Obama administration, responding to consumer complaints, says it will begin rating health insurance plans based on how many doctors and hospitals they include in their networks.

At the same time, the maximum out-of-pocket costs for consumers under the Affordable Care Act will increase next year to $7,150 for an individual and $14,300 for a family, the administration said. Consumer advocates said those costs could be a significant burden for middle-income people who need a substantial amount of care.

Under new rules to be published Tuesday in the Federal Register, insurers will still be allowed to sell health plans with narrow networks of providers. But consumers will know in advance what they are getting because the government will attach a label indicating the breadth of the network for each plan sold on HealthCare.gov.

Six of the 32 states implementing the Affordable Care Act’s Medicaid expansion to date have done so through Section 1115 waivers. Using these waivers, the Centers for Medicare and Medicaid Services has approved terms that extend beyond the flexibility provided by federal law. Section 1115 waivers authorize research and demonstration projects that, in the view of the Health and Human Services Secretary, further the purposes of the Medicaid program. The ACA implemented new requirements for these waivers, including that states must have a publicly available, approved evaluation strategy. States also must submit an annual report to HHS that describes the changes occurring under the waiver and their impact on access, quality, and outcomes.

State Medicaid agencies say Congress’ decision to suspend the Affordable Care Act’s tax on health insurers for one year is a good first step, but they are pushing for its permanent repeal.

While most private health insurance plans have had to pay the tax themselves, states that contract with Medicaid managed-care plans have had to cover the premium tax to ensure that the health plans receive actuarially sound rates. Thirty-eight states and the District of Columbia contract with Medicaid managed-care plans.