Tag Archives: ACA

Who’s affected by insurers’ pullbacks?

Aetna last week joined other health insurers in withdrawing from many of the health exchanges set up under the Affordable Care Act.

The company cited an unsustainable financial situation.

But that motive is being questioned: It was revealed last week that Aetna had earlier warned it would reduce its presence in the exchanges if the Justice Department sued to block its deal to acquire Humana.

The government filed that suit last month.

Regardless, this latest pullback from Obamacare leaves a lot of questions about competitive options in the exchanges, how consumers will be affected and the future of the law.

KHN’s Julie Rovner joined a panel of guests on The Diane Rehm Show on Aug. 18 to discuss the move and how it might affect the presidential campaign.

Made available by Kaiser Health News.

Report: Affordable Care Act rule saves consumers $9 billion on health insurance premiums

Consumers saved $9 billion on their health insurance premiums since 2011 because of the Affordable Care Act, according to Health and Human Services Secretary Sylvia M. Burwell.

The 80/20 rule, also known as the Medical Loss Ratio rule, requires insurers to spend at least 80 percent of premium dollars on patient care and quality improvement activities.

If insurers spend an excessive amount on profits and red tape, they owe a refund back to consumers.

“We are pleased that the Affordable Care Act continues to provide Americans better value for their premium dollars,” said Burwell in a news release. “We are continuing our work on building a sustainable long-term system, and provisions such as the 80/20 rule are providing Americans with immediate savings and helping to bring transparency and accountability to the insurance market over the long-term.”

An HHS report released on July 24 shows that last year consumers nationwide saved $3.8 billion up front on their premiums as insurance companies operated more efficiently.

Additionally, consumers nationwide will save $330 million in refunds, with 6.8 million consumers due to receive an average refund benefit of $80 per family.

This and other Affordable Care Act standards contributed to consumers saving about $4.1 billion on premiums in 2013, for a total of $9 billion in savings since the MLR program’s inception, according to HHS.

The report shows that since the rule took effect, more insurers are meeting the 80/20 standard by spending more of the premium dollars they collect on patient care.

If an insurer did not spend enough premium dollars on patient care and quality improvement, they must pay refunds to consumers in one of the following ways:

· a refund check in the mail.

· a lump-sum reimbursement to the same account that was used to pay the premium.

· a reduction in their future premiums.

New year, big tests for Affordable Care Act

The new year brings the big test of President Barack Obama’s beleaguered health care law: Will it work?

The heart of the law springs to life on Jan. 1, after nearly four years of political turmoil and three months of enrollment chaos. Patients will begin showing up at hospitals and pharmacies with insurance coverage bought through the nation’s new health care marketplaces.

The course of 2014 will show whether Obama can get affordable care to millions of people in need, without doing intolerable damage to the 85 percent of U.S. residents who already were insured.

Lots of Americans are nervous.

Will their new coverage be accepted? It’s a concern because insurers have reported problems with the customer information they’ve gotten from the government, including missing data and duplication.

How many more people will see old individual plans that they liked canceled? Will a flood of newly insured patients cause doctor shortages? Will businesses respond to the law by ditching their group plans or pushing more health costs onto workers?

About three-fourths of people who face changes to their job-based or other private coverage in 2014 blame the health law, a recent AP-GfK poll found. Yet the trend of employers trimming costly health benefits predates the law now widely known – by critics and advocates – as Obamacare.

Many people should benefit immensely.

People previously locked out of individual insurance by high prices or pre-existing health problems can get coverage to stave off the threat of medical bankruptcy. More low-income workers will come under Medicaid, in states that agreed to expand the safety-net program. Middle-class families without workplace coverage can get tax subsidies to help pay for their insurance. How much patients like the new plans, and whether they can afford the co-pays and deductibles, will become clear as they start visiting doctors.

The new year also launches the most contentious aspect of the law: the mandate that nearly everyone in the U.S. have health coverage, or pay a fine.

All this will unfold during the super-heated politics leading to November’s midterm elections.

Republicans and Democrats will jostle all year to influence the public’s assessment of changes to American health care not matched since Medicare and Medicaid were launched nearly a half-century ago.

Some dates – and moving parts – to watch in 2014:

JAN. 1

Coverage begins. Many low-income Americans who didn’t qualify for Medicaid in the past can use it now. People who signed up for private insurance in a state or federal marketplace by Dec. 24 (or later in some states) and have paid their first premium are now covered, too.

Coverage begins for workers at companies that have signed up for new small business plans through the marketplaces, also called health care exchanges.

Coverage lapses for people whose existing plans were canceled, if they haven’t signed up for a replacement or received an extension. At least 4.7 million people got cancellation notices, despite Obama’s promise that Americans with insurance they like could keep their old plans. Obama recently gave insurance companies the option of extending old plans for existing customers for a year, but only where state insurance commissioners give their OK.

The clock starts on the “individual mandate.” Nearly all U.S. citizens and legal residents are required to have “minimum essential coverage” for most of 2014, or pay a penalty. Most people already are insured through their jobs, Medicare, Medicaid, or military coverage and so don’t need to do anything.

Insurance companies are no longer allowed to turn away people in poor health or kick customers out of plans when they get sick.

Women and people with pre-existing conditions pay the same rates as healthy men in the new plans. The law also limits how much more insurers can charge older people.

New insurance plans can’t put an annual dollar limit on care, or require individuals to pay more than $6,350 in out-of-pocket costs per year.

JAN. 10

Payment due. In most cases, marketplace customers who signed up by Dec. 24 have until now to pay the first month’s premium and get coverage for their January medical bills. Major national insurers agreed to accept payments 10 days into the month because of technical troubles plaguing online enrollment at HealthCare.gov. But buyers should check early with their insurance companies – some may not honor the grace period. A few states running their own marketplaces are granting even more time. Those who miss their deadline can get coverage starting Feb. 1.

JAN. 31

A temporary program for people denied coverage because of poor health ends. Tens of thousands of Americans with serious illnesses such as heart disease and cancer were in the special program and needed new coverage for 2014. The Pre-Existing Condition Insurance Plan, originally set to expire Dec. 31, was extended one month to help sick people whose enrollment was stymied by HealthCare.gov computer crashes.

Some people could lose coverage for a prescription they’ve been taking. The Obama administration urged insurers to temporarily let customers keep filling prescriptions covered by a previous plan, but not their new one, through January.


The patched-up health care website will face a major test if too many people rush to sign up in the final days of open enrollment. Watch for a possible return of rampant crashes and error messages.

On the other hand, low enrollment signals another danger. The law’s design relies on younger, healthier enrollees to offset the cost of older and sicker consumers. If the numbers stay low, it’s likely that enrollees will be disproportionately people with more expensive medical needs, putting a financial strain on insurers. The White House set a goal of 7 million sign-ups for private coverage. More than 1 million had enrolled by Dec. 20, Obama said.


Last chance for open enrollment through the federal marketplace or 14 states running their own exchanges. Late March enrollees will be covered beginning May 1. (It’s possible the administration could decide to extend open enrollment, if major website problems resurface and interfere with sign-ups.)

This is the deadline for most people to get coverage to avoid a fine. The Obama administration says, however, that those whose existing health insurance was canceled because of the Affordable Care Act will be exempt from the penalty. People who lose coverage during the year can go without for three months before facing a penalty.

The enrollment deadline doesn’t apply to people signing up for Medicaid or the Children’s Health Insurance Program, based on income. People can apply for those programs at any time and coverage begins at once.

The March 31 deadline also won’t stop those who need to sign up later in 2014 because of a “qualifying life event.” The events include things like getting married, having a baby, or leaving a job that provided insurance. Qualifying events trigger a special enrollment period lasting 60 days.


No worries yet. Those who go without insurance won’t owe penalties until federal taxes are due in 2015 for the previous year’s income. Tax returns filed in 2015 will include health insurance information; insurers will send notices to confirm that taxpayers were covered in 2014. People who bought plans in the marketplaces and received either too little or too much in premium subsidies during the year also will square things with the IRS in April 2015.

NOV. 4

The midterm elections will be yet another referendum on the health care law passed in March 2010 with no Republican support. Obama will still be in the midst of his final term, however. So even if Republicans emerge with control of both chambers of Congress, they will still face two more years with Obama in the White House to veto attempts to undermine his signature law.

NOV. 15

Open enrollment for 2015 begins. Americans can sign up for insurance or switch to a different plan. And they’ll see what rate increases are in store for the coming year.

DEC. 31

The extension ends today for people who were able to keep their old individual plans for an extra year, even though the coverage wasn’t up to the law’s minimum standards.


JAN. 1

Large employers – those with more than 50 employees – that don’t offer health plans face a possible tax penalty. The penalties are designed to discourage businesses from dropping their existing health plans, although some have already begun to do so.

JAN. 15

Open enrollment for 2015 ends.


Penalties for individuals who weren’t insured in 2014 kick in. The penalty is $95 or 1 percent of income, whichever is higher. It goes up in later years. The IRS can deduct the penalty from a taxpayer’s refund.


So-called “Cadillac health plans” offered by some employers come under a new tax. It hits plans that spend more than $10,200 per worker or $27,500 for a family. Most job-based coverage isn’t that generous, but corporate executives get such plans, and so do some workers in jobs with strong union contracts. Some companies will pass the tax on to workers and others may trim employee benefits to avoid it.

Health care rollout is a national disgrace

In the initial weeks of full implementation, the Affordable Care Act was marred by computer glitches that left hundreds of thousands — if not millions — of consumers in the lurch. Healthcare.gov, the Web portal established for Americans to purchase health insurance through federal exchanges, is a travesty.

Residents of individual states that created their own insurance exchanges are faring better under the ACA. But the dysfunctional Web portal set up for the federal exchange has let down the citizens of Wisconsin and other states where Republican leaders refused to establish state exchanges.

Americans who are reliant on the exchanges earn 400 percent or less of the federal poverty level. Most of them live in impoverished states. The ACA provides them with subsidies to help pay their insurance premiums, but they must register in order to receive this benefit.

Unfortunately, the majority of people who’ve attempted to register on healthcare.gov have failed. They’ve waited for hours to get on the website, only to find that the system is incapable of finalizing their applications. According to local industry insiders, only about 50 people in southeastern Wisconsin had been able to apply successfully in the first two weeks.

How did this happen? The law was passed three years ago, giving the Obama administration ample time to execute an effective website. By dropping the ball on the president’s signature legislation, his own administration has left millions of people in a panic and thrown a meaty bone to conservatives who argue that government is incapable of managing such complex programs.

We grudgingly supported the ACA, despite our belief that a single-payer system would have been fairer and more cost-effective. But we strongly endorsed the new law’s fundamental features, including: ending the denial of coverage based on pre-existing conditions; lowering health-care costs by expanding the risk pool and halting the practice of uninsured people using emergency rooms as primary care providers; eliminating lifetime limits on coverage; prohibiting insurers from dropping coverage or raising premiums due to illness; capping annual out-of-pocket medical and drug expenses at $6,400 for individuals and $12,800 for families; and ensuring that children can remain on their parents’ coverage until age 26.

People who can afford their own plans or receive coverage through their employers will enjoy these essential improvements to the system. But low-income citizens who are unable to register for federal subsidies will find the insurance market is out of their reach.

Although the enrollment phase of the program lasts though March, people who don’t register by Dec. 15 could face devastating gaps in their coverage if their current policies expire before their new ones are processed. The Department of Health and Human Services must now work 24/7 to guarantee the website is functioning effectively before that can happen.

And the White House owes the nation more than its initial excuse that the system failed because it was overcome with so many people signing up at once when it went live on Oct. 1. That’s hogwash. Unofficial reports are that testing did not even begin on healthcare.gov until the waning days of September. 

The administration was caught unprepared to implement the most contentious law the nation has seen in decades — a law that cost Democrats control of the House and nearly cost them the presidency. That makes this failure of the White House far more than shoddy — it’s downright terrifying.

The mixed blessings of Obamacare

There’s a lot to celebrate with the Affordable Care Act. If you lose your job, you can still get health coverage for you and your family at an affordable price.  An insurer can’t turn you down due to a pre-existing condition. You’ll still have a choice of policies and similar access to doctors.

But the ACA represents everything that’s wrong with our political leadership.

The Obama administration had good reason to try fixing our tattered, expensive and bizarrely inefficient health care system.  A panel of doctors, epidemiologists, demographers and other researchers brought together by the National Research Council and the Institute of Medicine released a report in January concluding that U.S. health care ranks last in effectiveness among the world’s 17 developed nations. Meanwhile, it’s the second most expensive, even though, unlike other countries, it has huge gaps in coverage.

The legislation is the president’s hallmark achievement, and so Republicans want to make it fail far more than they want to save people’s lives. One of the worst offenders is Gov. Scott Walker, who hopes to ascend to the White House by preventing as many people as possible from gaining the benefits of health care reform.

But Obama and the Democratic Party gave critics fodder by creating an overly complex law designed to please the monied interests and win over right-wing critics rather than a law to provide citizens with the most affordable and expansive coverage possible. Fearing the demagoguery of critics slinging terms like “socialized medicine,” Barack Obama shackled us with a half-assed law so weighted down by bureaucracy and exceptions that it’s impossible to explain – and difficult to defend.

Other industrialized nations have some form of a single-payer plan. In those countries, rich people can still get whatever care they want, and poor and middle-class citizens get better coverage for a far lower cost than we do under the ACA.

One reason for that lower cost is cutting out the middle man: the insurance companies. For instance, United HealthGroup CEO Stephen Hemsley was paid nearly $13 million in 2012 – to do what? There are rich CEOs like Hemsley at scores of health insurance companies, and they have deputies under them who also receive extravagant salaries and bonuses without directly helping a single patient. Under Obamacare, insurance companies are mandated to spend a reasonable portion of premiums they collect on providing actual health care. 

The bottom line is that Obamacare is both a failure and a vast improvement. Ultimately it might lead to the single-payer plan that it should have been from the get-go.

Ignore all the lies about Obamacare coming from the tea party. Jump in and learn all you can about it for yourself by going to government Internet sources. Make the most of it and it will improve your life.

And then dream what could have been if we didn’t live in such a corrupt, ignorant and politically cutthroat society.

For more, go to obamacarefacts.com.

Man sentenced for attacking wife after discovering alleged affair with Walker’s former health care czar

A man allegedly cuckolded by Gov. Scott Walker’s former Department of Health Services Secretary was sentenced today for the brutal assault of his ex-wife.

Dane County Circuit Judge William Hanrahan sentenced Andrew Spear, 60, to 225 days in jail for an August 2012 attack in a Madison storage shed.

Spear was originally charged with taking his wife Mary Spear to the storage shed, beating her and then trying to set her on fire before she escaped. He subsequently fled town.

In a plea deal, Spear pleaded guilty last month to a felony charge of bail jumping and six misdemeanors for the horrific assault, which his lawyers said was motivated by his discovery of an extramarital affair between then-Walker cabinet secretary Dennis Smith and Mary Spear.

The case was marked by legal wrangling over emails between Mary Spear and Smith, who denied claims by Andrew Spear’s defense team that he reacted after discovering telltale communications revealing their romantic affair.

Smith, a health official in George W. Bush’s administration, is considered a leading architect in the GOP’s campaign to derail the Affordable Care Act. Smith formerly served as Walker’s Department of Health Services Secretary and, until his resignation, led the Walker administration’s attack on BadgerCare and the implementation of the ACA in Wisconsin.

Smith, who was formerly a senior fellow at the ultra-conservative Heritage Foundation, left the Walker administration in February soon after the news of his alleged affair with Mary Spear became public. Smith moved to Washington and joined a powerful K Street lobbying shop.

Smith brought Mary Spear with him to Madison by appointing her to serve as the $8-billion agency’s top lawyer. The appointment prompted howls of protests from critics who said she was woefully unqualified for the position.

In a rambling statement released last year after the assault, Smith “categorically” denied allegations of an improper relationship with Mary Spear, calling her a grade-school chum from their childhood in rural Illinois.

Smith said he hired Mary Spear over other, more experienced candidates not because of a personal relationship, but because he had been “impressed” by an obscure paper she’d written about health insurance that she’d asked him to proofread.

The Walker administration did not immediately respond to press inquiries about the governor’s knowledge of the alleged affair and whether he’d ordered Smith’s separation.

Jennifer Miller, a DHS spokesperson, said Mary Spear had not worked at the agency “for more than a year.”

Smith did not respond to inquiries.

Smith’s biography at McKenna, Long & Aldridge, a powerhouse K Street lobbying shop, claims that he’s worked to expand health care coverage nationwide.

But since his time in the Bush administration, Smith has fought expanded health care access. As a top federal official, he sought to limit Wisconsin’s successful SeniorCare program that provides prescription drug coverage. His effort was thwarted by then-Sen. Herb Kohl.

In Wisconsin, Smith used his bureaucratic know-how to mount a campaign to hobble the implementation of ObamaCare. Several times, federal health officials overruled his efforts to curtail benefits, including his attempt to kick 30,000 children off BadgerCare.

A frequent Smith critic, Milwaukee Rep. Jon Richards, described him as a “radical.”

“He had this almost fanatical approach to health programs that ignored the needs of day-to-day people,” Richards said.

Advocates urge state action on ‘Obamacare’

The Patient Protection and Affordable Care Act is out of the ER after an extensive examination by the U.S. Supreme Court.

Now, advocates of health care reform are prescribing action in the states that refuse to implement the landmark legislation, including Wisconsin.

“Our continuing challenge will be to make sure that states opt to expand Medicaid so that more low-income people, and particularly those with HIV, can get the health care they urgently need,” said Scott Schoettes, the HIV project director for Lambda Legal, a civil liberties group based in New York.

Lambda filed an amicus brief defending the ACA before the High Court, which, on June 28, released its 5-4 decision upholding key elements of the most significant health care reform in the United States since the creation of Medicare and Medicaid in 1965.

The act contains many provisions, some of them already being implemented at the federal level; others are set to go into effect in 2013 and 2014. The legislation:

• Prohibits insurance companies from canceling or denying coverage due to a pre-existing condition and from charging women more than men.

• Requires insurers to provide certain free preventive care, such as mammograms for women and wellness visits for seniors.

• Provides for rebates from insurance companies that spent too much from health care premiums on administrative costs and corporate bonuses.

• Guarantees continued prescription drug savings for seniors.

• Enables young adults to stay on family insurance plans.

• Creates insurance exchanges for people and businesses to find the best coverage for the best price.

• Bans discrimination in coverage and care, including discrimination based on sexual orientation and gender identity.

The most controversial provisions of the act were taken to the High Court: the requirement that people secure health insurance – the so-called individual mandate – and the expansion of Medicaid to guarantee care for lower-income people.

Chief Justice John Roberts wrote the majority opinion, joined by Sonia Sotomayor, Stephen Breyer, Elena Kagan and Ruth Bader Ginsburg. Anthony Kennedy, Antonin Scalia, Clarence Thomas and Samuel Alito dissented.

Roberts wrote that the individual mandate can stand, as a tax, which Congress has the authority to enact.

“This ruling is a victory for millions of people – including LGBT people and our families – who don’t have access to adequate, affordable health care,” said Rea Carey, executive director of the National Gay and Lesbian Task Force in Washington, D.C.

Kali Lindsey of the National Minority AIDS Council said, “The ACA does more to improve America’s response to the HIV/AIDS epidemic than any piece of legislation since the Ryan White CARE Act. Whether banning the practice of denying cover- age to Americans with pre-existing conditions like HIV infection, or caps on lifetime expenditures, this law will improve access to care for hundreds of thousands of people living with HIV.”

But the Court’s ruling on the expansion of Medicaid caused concern.

“That the Medicaid expansion must be voluntary means that millions of low-income Americans, including thousands living with HIV, may still lack access to the program,” Lindsey said. “The law’s subsidies, which are aimed at helping individuals purchase insurance through state health exchanges, were not designed to cover those who would have otherwise been eligible for Medicaid under the expansion.”

The ACA provides for an expansion of Medicaid to cover people with incomes up to 133 percent of the federal poverty level. Under the law, the federal government would cover the costs of the expansion until 2017, when the states would absorb some expenses.

But the Court said the federal government cannot withhold all Medicaid funds from states that decline to take part in the expansion. So, states can decide not to enter the expansion without fearing the loss of funds.

At least seven governors, including Gov. Scott Walker have indicated they will not participate in an expansion of Medicaid. And            eight governors lean toward a “no.”

Walker said he would implement no aspects of the Affordable Care Act – now both derided and cheered as “Obamacare” – before the November election. That’s close to the deadline when states must tell the federal government whether they will build health-insurance exchanges.

“While the Court said it was legal, that doesn’t make it right,” Walker said at a news conference. “For us to put time and effort and resources into that doesn’t make a lot of sense.”

That’s an opinion shared by a number of other Wisconsin Republicans in the days after the Supreme Court ruling. Those at the federal level, such as U.S. Rep. Jim Sensenbrenner, vowed to work for a repeal.

“The individual mandate is a massive infringement on our freedom, and it’s bad policy,” he said.

Wisconsin Democrats, meanwhile, cheered the ruling and praised the law.

U.S. Rep. Gwen Moore said, “So many in my home state of Wisconsin will benefit and are already benefitting from the ACA. They can now breathe a sigh of relief that they will continue to benefit from critical patient protections, lower costs, expanded coverage and greater account- ability from the insurance industry.”