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Pre-X Redux

With the focus now mainly on exchanges, Medicaid expansions, and enrolling the uninsured in newly available coverage arrangements, there is less attention lately to the ACA insurance reforms which have always been the most popular parts of the law – changes which could affect every American’s insurance in some way…

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Covering The ACA May Be Almost As Hard As Implementing It

This Pulling It Together was adapted from a column I published earlier this week in Politico, with a new introduction added. You can read the original Politico column here. The implementation of the ACA is news and the public will demand information about it. Journalists and news organizations have an obligation…

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Can We Learn From ACA Implementation and Improve the Law?

Senator Baucus made headlines recently when he predicted a “train wreck” for Obamacare. David Brooks predicted “chaos” in a recent column. In a news conference, the President offered a different perspective.  “There’ll still be, you know, glitches and bumps…. That’s pretty much true of every government program that’s ever been…

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Questions for 2014

Today’s discussion of the Affordable Care Act (ACA) is focused on immediate implementation milestones leading up to 2014 when the law’s major provisions are set to kick in.  This is a critical period when the foundation for the ACA is being established and key building blocks such as the state…

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On Health Care, Conservatives Protest Too Much

Lately conservatives have been feeling like losers in health care and complaining loudly about it. They don’t like Obamacare or the increase in the government’s role in health care or the federal spending it brings with it, even if those things result in coverage for more than 30 million uninsured…

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The News Media and “Entitlement Reform”

In the coming debate about the deficit, policymakers will struggle to craft a package of spending reductions and new revenues that both Democrats and Republicans can agree on, totaling as much as four trillion dollars over ten years.  Medicare, Medicaid and potentially the Affordable Care Act will have their turn…

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                    [post_date] => 2013-06-20 09:00:41
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                    [post_content] => With the focus now mainly on exchanges, Medicaid expansions, and enrolling the uninsured in newly available coverage arrangements, there is less attention lately to the ACA insurance reforms which have always been the most popular parts of the law – changes which could affect every American’s insurance in some way and which go into effect regardless of the implementation decisions states make.  In this column, I draw on our recent tracking polls to review where the public stands on the most prominent of these insurance reforms – guaranteed issue. This is another area where information could matter because many people with pre-existing medical conditions who stand to benefit from the law don’t seem to know about it.

Forty-nine percent of the American people under the age of 65 report that they or a family member have a pre-existing medical condition such as heart disease, diabetes, asthma, and cancer. Among this group, a quarter (25%) say that they or someone in their household has been denied coverage or had their premium raised because of a pre-existing condition.

Thirty-five percent say they worry that they will have to pass up a job opportunity or forego retirement plans to maintain coverage and nearly one in ten (9%) say they or someone in their household has passed up a job opportunity or decided not to retire in the past year because of “job lock”.

The “guaranteed issue” requirement in the ACA fixes this problem, which is called medical underwriting. It requires insurers to issue health plans to anyone in the individual or group markets, regardless of their health status, and prohibits rate surcharges based on health status in the individual and small group markets.  Like most of the ACA’s major revisions, it kicks in January 1 of next year, with open enrollment beginning this October.

The provision is popular; 66% of the American people support it. It is also one of those ACA provisions Republicans like, with 56% of Republicans supporting it. The President has talked about it often, journalists have publicized it, and experts have debated the impact of eliminating medical underwriting on the costs of insurance since passage of the law.  But like many elements of Obamacare, many people who will benefit from it don’t seem to know about it. Among those who report that someone in their household has a pre-existing condition, four in ten are not aware of the guaranteed issue provision. Just like the other group who will benefit most from the ACA, the uninsured, a large number – in this case half of all people who have someone in their household with a pre-existing condition – say they don’t have enough information about the ACA to know how it will impact them or their family.

Not everyone with a pre-existing condition has had a problem getting health insurance. People with employer-based coverage are protected under the previous law unless they lose their job and experience a coverage gap. Nor does liking the idea of guaranteed issue necessarily mean someone will support the ACA; people like or dislike the ACA for various reasons. And, there are tradeoffs in eliminating underwriting against people with pre-existing conditions. Premiums may rise somewhat to accommodate coverage for people who are sick (the idea is to balance this to some extent by insuring people who are young and healthy as well).

But there is a large constituency of people with major illnesses who will benefit from the law who do not seem to know it, and virtually everyone benefits from the peace of mind of knowing that if they get sick they no longer can be denied coverage or priced out by surcharges, even if they have large group coverage and lose it. Right now, working people who get sick and need to leave their jobs have only expensive COBRA coverage as a temporary solution.

The ACA awareness and outreach effort now getting underway is aimed more at the goal of connecting the uninsured to new coverage opportunities than helping people to understand the security of knowing that they can’t be denied coverage if they get sick. There is obvious logic in that, since the law cannot succeed without getting people enrolled. But, many people with pre-existing conditions such as cancer, heart disease, or diabetes are represented by organized and usually very effective disease groups. They have a role to play in informing their constituents about this issue as do health professionals whose patients may benefit from the guaranteed issue provision. Fifteen percent of those with a pre-existing condition say they have talked with their doctor or a medical professional about the ACA.

One reason this is important now: as the economy improves, people will be looking for better job opportunities, and there is a significant group of people still afraid to change jobs because they are sick and who seem not to know that they soon will not have to worry about that anymore.

________________

(Note: In this column, I report data on pre-existing conditions from our March, April and June 2013 Kaiser Tracking Polls and our September 2011 Tracking Poll. I focus on the non-elderly because seniors are protected from medical underwriting by the Medicare program.)
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                    [post_content] => This Pulling It Together was adapted from a column I published earlier this week in Politico, with a new introduction added. You can read the original Politico column here.

The implementation of the ACA is news and the public will demand information about it. Journalists and news organizations have an obligation to cover this story.  As Kaiser CEO I serve as the publisher of our non-profit news service, Kaiser Health News, and also as the head of our large health policy information and analysis enterprise, so I see ACA implementation from a variety of perspectives. The ability of journalists to cover the ACA accurately and in depth will be related to our ability in the health policy community to provide facts, data, and evidence on ACA implementation in near real time, and to provide expert analysis journalists can rely on. Ultimately it will also depend on our ability to evaluate the impact of the law on coverage, access, people’s financial burdens, and overall health care spending, and to do it in a time frame that is not so slow that public and political judgment on the ACA has already been rendered. This column addresses the challenges journalists face covering the ACA, but ACA implementation confronts the health policy community with challenges that are at least as formidable as those faced by journalists. They will be the subject of another column.
Covering The ACA May Be Almost As Hard As Implementing It
President Barack Obama recently predicted “glitches and bumps” when major provisions of the Affordable Care Act are implemented next year. It is always this way. Today we think of Medicare as a popular program that is part of the fabric of American life. But my friend Joseph Califano, who helped create Medicare while working for Lyndon B. Johnson, recalls real problems during the early days of the program, including resistance to desegregating hospitals and physician reluctance to participate. But there is at least one big difference today: Our almost instant and nonstop news cycle, the Internet and the impact of the news echo chamber on the public. As several news organizations learned during last summer’s coverage of the ACA ruling in the Supreme Court, it’s better to be right than to be first. Getting the ACA story “right” will be nearly as difficult as implementation itself. Here are four major challenges all news organizations will face. These are challenges we face too at Kaiser Health News. 1. The biggest challenge is that ACA is no longer a Washington story. As the story moves to the states, national news organizations will need to cover the law’s implementation beyond the Beltway and explain what it means for the American people. Few national news organizations have the “eyes and ears” across the country to do this well, and regional and local news organizations do not have the on-staff health policy expertise, even if they have the local ties. This is a challenge for us at Kaiser Health News, with a staff of reporters and editors based mostly in Washington. We are establishing partnerships with regional newspapers, NPR affiliates and others, so that together we can spot the most relevant state and local stories to report them locally and nationally through our distribution partners. Other news organizations will find their own answers. 2. Another challenge will be judgment by anecdote. Critics will feed reporters ACA horror stories and supporters will sell them success stories. Every journalist will be able to find a bad ACA story or a good one. When does “one” person’s experience represent “many,” or “most”? The gold standard is to take examples from a statistically representative group using a scientifically valid survey, but that’s just not going to happen very often with reporters working under deadlines. Journalists will need to do interviews, check with experts, scrape together what early data exist and make judgment calls about whether the anecdote they have is an outlier or representative of broader experience. Let’s say Bill Smith in Arkansas chains himself to the IRS building and refuses to pay his fine in protest of the law’s requirement that Americans buy health insurance, but that overall, the mandate works smoothly, as it has in Massachusetts. No doubt, Smith will be “breaking news” on your favorite cable channel. With complex stories like ACA, there is a temptation to cover only breaking news and not the broader story. These news judgments matter because powerful anecdotes stick in the public mind in ways statistics never will. 3. A third challenge is deciding what to cover. When the “death panel” story broke, many news organizations sprang into action to fact check and debunk the claim. Cable news covered the story day after day. No doubt the repeated coverage of nonexistent death panels contributed to public anxiety about the law. Today, 40 percent of the American people still believe there are death panels in ACA. News organizations need to make their own judgments about what is important to cover and be on guard against being manipulated by the political process. The decision about what stories to cover can be even more important than how to cover them. 4. Finally, there is the “balance trap” — the pressure to present the views of the organized right and left rather than the facts. This is a general problem for journalism today but one that is particularly relevant to ACA because views on it are so sharply divided along partisan lines. I recently moderated a panel with three top journalists from The New York Times, NPR and The Wall Street Journal. All three said that the pressure to do just this was their biggest challenge covering health reform in a hyperpartisan Washington. It is not always easy to find the facts, and sometimes issues are maddeningly gray in health policy. But often the facts are clear in statute or regulations. They are in a government report or a study from a respected organization. Our polls show that the public remains only dimly familiar with the details of ACA, and those who stand to gain the most (the uninsured or people with pre-existing medical conditions) often know the least. As the main elements of the law are implemented, efforts are being mounted by the federal government, states and nonprofit organizations to inform people. As important as these targeted awareness and outreach efforts will be, the news media have always been the public’s main source of health information. And while local TV news has traditionally been the public’s top source of health news, newspapers, radio, online news and cable news are closely bunched as their top sources of information about ACA. How well news organizations step up to these and other ACA coverage challenges will have a big impact on implementation of the law and public judgment about it. [post_title] => Covering The ACA May Be Almost As Hard As Implementing It [post_excerpt] => [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => covering-the-aca-may-be-almost-as-hard-as-implementing-it [to_ping] => [pinged] => [post_modified] => 2014-03-04 11:14:33 [post_modified_gmt] => 2014-03-04 16:14:33 [post_content_filtered] => [post_parent] => 0 [guid] => http://kff.org/?post_type=perspective&p=74512 [menu_order] => 0 [post_type] => perspective [post_mime_type] => [comment_count] => 0 [filter] => raw ) [2] => WP_Post Object ( [ID] => 70869 [post_author] => 48572675 [post_date] => 2013-05-07 09:00:20 [post_date_gmt] => 2013-05-07 13:00:20 [post_content] => Senator Baucus made headlines recently when he predicted a “train wreck” for Obamacare. David Brooks predicted “chaos” in a recent column. In a news conference, the President offered a different perspective.  “There’ll still be, you know, glitches and bumps…. That’s pretty much true of every government program that’s ever been set up,” Obama said. “But if we stay with it, and we understand what our long-term objective is, which is making sure that in a country as wealthy as ours, nobody should go bankrupt if they get sick, and that we would rather have people getting regular checkups than going to the emergency room because they don’t have healthcare, if we keep that in mind, then we’re going to be able to drive down costs.” There are always problems in big government programs and unintended consequences that could not be predicted in advance of implementation. The longer term question is not whether there will be problems – there will be glitches and there will be even more successes as people gain coverage and insurance is reformed – but whether the political system today has the capacity to learn from implementation, adapt and make improvements. In the history of domestic programs there are few if any examples of “train wrecks” or “chaos”. Yes, Medicare Catastrophic was, well catastrophic, but it was never implemented.  Social Security, Medicare, and Medicaid were all implemented reasonably smoothly. In the ACA, like Medicaid or welfare, states bear a lot of responsibility for implementation and administration and there will be substantial variation in performance across the states. Some view that as a problem and some see it as a strength. One under-appreciated aspect of the ACA is how fundamentally the Supreme Court changed the law when it made the Medicaid expansion a state option. Many governors also waited for the outcome of the election to decide what they would do. The result is that the program being implemented is, in important respects, not the same as the one originally envisioned in the statute. There is no doubt states will make adjustments as implementation proceeds and they learn what is working and what is not in their exchanges and Medicaid expansions. Right now only seven states are planning “active purchaser” exchanges that, among other things, more aggressively try to control premium increases among plans offering business in their exchanges. One prediction I will make (it could be wrong) is that over time more states running their own exchanges will move away from the passive Expedia.com model exchange towards a more active purchaser model. HHS will also have the ability to make changes through administrative authority, waivers, and new regulations. The question is the Congress. Typically the process of learning from experience culminates in Congress with new legislation. Welfare reform legislation, for example, began in the Reagan years but was revisited comprehensively in the Clinton years. And both Medicare and Medicaid have been substantially modified through successive waves of legislation over the years. Laws are changed as we learn what works, as needs and circumstances change, and as political support for needed changes coalesces. Can today’s hyperpartisan, largely paralyzed Congress agree on legislation to improve ACA as we learn from implementation? Would Republicans agree to anything Democrats want? Would Democrats open up the ACA for legislative tinkering? It is not easy to envision agreement on ACA-related legislation any time soon. One thing that could change the picture somewhat is the current negotiations occurring between several states and the administration over the Medicaid expansion. If HHS and these states can successfully negotiate arrangements that give the states the flexibility they want and at the same time provide adequate protections for beneficiaries, it will bring more red states and their governors into the fold and create a much more bipartisan base for the ACA in the states than it has had in Washington, as well as a broader constituency for changes to improve the law over time. This will not happen overnight. Another factor that will affect the ability to learn and adapt as implementation proceeds is media coverage. If journalists focus on both what is working well as well as what is not, they can make a real contribution not only to public judgment about the ACA but future efforts to improve it. If they focus only on gotcha outlier horror stories that do not reflect general experience with the ACA, their reporting will do more to fuel political partisan debate than inform future policy. Of course the Congress itself could change in coming years, but with only thirty to forty seats up for grabs in the House of Representatives and the others mostly safe districts that lean right or left, redistricting has baked a certain degree of polarization into Congress for the immediate future. As implementation unfolds there are as many questions about the ability of our political system to learn from implementation and respond intelligently to the ACA as there are about the ACA itself. [post_title] => Can We Learn From ACA Implementation and Improve the Law? [post_excerpt] => [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => can-we-learn-from-aca-implementation-and-improve-the-law [to_ping] => [pinged] => [post_modified] => 2014-03-04 11:14:34 [post_modified_gmt] => 2014-03-04 16:14:34 [post_content_filtered] => [post_parent] => 0 [guid] => http://kaiserfamilyfoundation.wordpress.com/?post_type=perspective&p=70869 [menu_order] => 0 [post_type] => perspective [post_mime_type] => [comment_count] => 0 [filter] => raw ) [3] => WP_Post Object ( [ID] => 68402 [post_author] => 5093470 [post_date] => 2013-03-22 09:52:28 [post_date_gmt] => 2013-03-22 13:52:28 [post_content] => Today’s discussion of the Affordable Care Act (ACA) is focused on immediate implementation milestones leading up to 2014 when the law’s major provisions are set to kick in.  This is a critical period when the foundation for the ACA is being established and key building blocks such as the state Medicaid expansions, exchanges, and a host of regulations about other elements of the ACA being produced by HHS are getting our attention. But there is also an ACA horse race mentality threatening to take over: Is this or that regulation on time or late?  How many states have committed to the Medicaid expansion so far or to one kind of exchange or another?  Will every element of the ACA be ready to go in 2014 as envisioned in the legislation? Is the ACA succeeding or failing?  Everybody is keeping score.  In a partisan Washington with a gotcha media, it’s easy to get lost in the weeds.  Here are five big picture questions to keep in mind about the ACA.
1. As Republican governors slowly come on board, can the ACA make the transition from an ideological and partisan war zone to a more bipartisan effort to benefit people, with more traditional tensions between Washington and the states over money, flexibility and control?
Governors, historically more pragmatic than ideological, may be reverting to form and could give the ACA the bipartisan support on the ground it has not had in Washington.  It is still too early to say if the Republican governors will actually change the politics of the ACA. Conservative legislatures in some states, including Florida, are putting up resistance to their governors' decisions.  Some governors are also putting their own twist on how their Medicaid expansions will operate, to distance themselves from Obamacare at the same time as they embrace the Medicaid expansion and substantial federal funding for it (though not necessarily the exchanges and the rest of the law).  More of this two-step - embracing while distancing - may be necessary to bring conservative state legislatures along.  It is possible that the governors, pushed by providers in their states and local government and their own sense of pragmatism, will slowly transform the ACA from a partisan conflict to a more typical federal-state program with more traditional state-federal tensions over money and control. To be clear, it is the federal money and the potential to provide coverage for their citizens which is moving the Republican governors, not some overnight conversion to Obamacare, but the longer term result could be a much more bipartisan complexion for the law.
2. Will there be a rush to judgment in 2014 when there are inevitable early implementation stumbles and enrollment builds more slowly than expected?
It may be time to recalibrate expectations about timetables set originally to pass legislation to reflect new realities.  Since the ACA passed, the Supreme Court effectively made the Medicaid expansion a state option.  Many governors and legislators also waited for the outcome of the election to decide whether or not to move forward on ACA implementation.  As a result, the ACA being implemented now is no longer exactly the same health reform law that passed the Congress, and the circumstances affecting implementation have changed.  Already the Congressional Budget Office (CBO) has adjusted their enrollment projections. It will take time for enrollment to build up as new systems and outreach efforts gear up. Our newest tracking poll shows that the public remains confused about what the ACA does, including groups like the uninsured who will benefit most. This is not surprising, since mostly what the public has heard for three years is partisan bickering about the ACA. Only now as we head for implementation of its key provisions in 2014, is the ACA beginning to be introduced to the public for real.  This transition point from political talking point to reality is both a challenge and a critical opportunity for the law. To be clear, implementation deadlines should not be changed.  People have waited long enough for the coverage and other benefits the ACA will provide; and if they are changed, the implementation effort will slow accordingly.  Quite the contrary, now is the time for an all-out implementation effort.  But expectations may now need to be adjusted to reflect post Supreme Court realities and the uncertainties of current federal budget debates.
3. Will there be a backlash to the individual mandate and the law in general if some people find the policies they are now required to buy unaffordable, especially those who will not be receiving premium subsidies in the exchanges?
Policies available in the exchanges will provide far better value than those offered today in the largely broken non-group market.  Even so, the affordability of bronze and silver plans as perceived by people who buy them, not by experts calculating their actuarial value in advance of implementation, will be a critical moment for the ACA.  And people will be required to buy these policies.  The mandate worked smoothly in Massachusetts, the only place where it has been tried.  The citizens of the state like the program and by all accounts no one ran from Massachusetts for Rhode Island or New Hampshire because of the mandate.  Does that mean the ACA’s mandate will work smoothly in the rest of the country?  The vast majority of people buying policies in exchanges will like the deal they are getting but some may not.  How will the press handle a relatively small number of people experiencing rate jitters?  How will policymakers respond?
4. If, as I suspect, costs begin to rise again when the economy strengthens, will that be blamed on the ACA?
It should not be.  The ACA supports important Medicare payment and delivery experiments.  It also has provisions (medical loss ratio thresholds and rate review) that put downward pressure on premium increases in some parts of the market.  And it is entirely plausible (to me) that the ACA has precipitated a market response beyond its own Medicare pilot projects resulting in changes in payment and delivery and at least temporary cost moderation, just as the mere threat of health reform legislation has done in the past.  But the ACA is neither the cause of nor the ultimate solution to the larger problem of rising health care costs.  The causes of the recent slowdown in health costs are a much bigger topic that we will be addressing in a forthcoming analysis.  We have seen slowdowns in health costs before and they have always been followed by upticks. It is  important to understand when the slowdown started, how much of it is due to the effects of the weak economy on utilization or, potentially, to changes in health delivery and financing, and what the future outlook might be.
5. In the hyper-partisan political system we have with today’s media, is there the capacity to learn from implementation so health reform can continue to be reformed and improved?
The idea that you pass a law, write regulations, implement it, and then judge its success or failure bears little relationship to how programs do or should work.  Not everything can be anticipated when legislation is written, and much that goes into legislation is designed to win enough votes for it to pass rather than for it to work optimally in the real world. This legislation too was passed without the normal reconciliation between House and Senate plans, which offers opportunities to fix problems in the law and choose the best of both approaches. Circumstances also change as programs are implemented.  Reflecting this, Medicare and Medicaid have changed substantially over time.  Can adjustments to the ACA be made in this Congress?  In the states?  By our current largely frozen political system? The kinds of changes often made to improve legislation do not seem possible in the current Congress. In 2014 there will be an ample supply of both early ACA success stories and stumbles.  It will take years for scientific evaluations to measure the impact on access and financial burdens and other outcomes.  The year 2014 is merely the date when major ACA provisions begin, and it will take years beyond 2014 before it is clear how many states undertake Medicaid expansions or what the ultimate mix of state versus federal exchanges is and how many people ultimately benefit from the ACA’s coverage expansions.  While no doubt some will try, 2014 is not the right time to declare success or failure for the ACA any more than 1966 was the right time to do the same for Medicare or Medicaid. [post_title] => Questions for 2014 [post_excerpt] => [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => questions-for-2014 [to_ping] => [pinged] => [post_modified] => 2014-03-04 11:14:34 [post_modified_gmt] => 2014-03-04 16:14:34 [post_content_filtered] => [post_parent] => 0 [guid] => http://kaiserfamilyfoundation.wordpress.com/?post_type=perspective&p=68402 [menu_order] => 0 [post_type] => perspective [post_mime_type] => [comment_count] => 0 [filter] => raw ) [4] => WP_Post Object ( [ID] => 71223 [post_author] => 36621681 [post_date] => 2013-01-21 09:34:54 [post_date_gmt] => 2013-01-21 14:34:54 [post_content] => Lately conservatives have been feeling like losers in health care and complaining loudly about it. They don't like Obamacare or the increase in the government's role in health care or the federal spending it brings with it, even if those things result in coverage for more than 30 million uninsured Americans and new protections from the worst abuses in the health insurance industry. Actually, conservatives are winning at least as much as they are losing in health care, even if they don't know it or won't say it, because out in the real world of health insurance, beneath the politicized debate about Obamacare, the vision of health insurance they have always championed -- high deductible plans that give consumers lots of "skin in the game" -- is steadily prevailing in the marketplace. Moreover, the conservative vision of "skin in the game" insurance could actually get a boost from the health reform law. Half of all workers in small firms now pay deductibles of $1,000 or more a year, and the percentage of workers in all firms paying big deductibles has tripled in the last six years. In the last five years the average deductible for single coverage has gone from $616 to $1,097 in all firms that have deductibles, and from $852 to $1,596 in small firms. Estimates are that in the basic plan offered in the health insurance exchanges under the Affordable Care Act, deductibles could be over $4,000 for individual policies and over $8,000 for family policies. These are big deductibles by any standard. Yes, the minimum coverage people will have to buy under Obamacare will be just the kind of "skin in the game" insurance that conservatives have always favored. But from start to finish, the health care reform debate has not been about facts but about ideology and partisanship. Conservatives are certainly not happy that the Affordable Care Act has survived a Supreme Court challenge and an election and will now be implemented and will not be repealed. But even as they continue to vilify the law, they must take solace in the fact that many states are still balking at implementing major provisions that conservatives do not like, such as the law's insurance exchanges or its Medicaid expansion, which the Supreme Court made optional. Only 18 states and D.C. have chosen to implement their own insurance exchanges, and only seven are planning exchanges that are active purchasers, the more aggressive kind of exchange that liberals and consumer advocates would like because they weed out plans with high premiums. The success of the Affordable Care Act now hinges on implementation, and more than any other single factor, the fate of the law will depend on what states do and how well they do it. The federal government will step in and operate exchanges in states that choose not to do so, but there is no federal fallback on Medicaid; if a state like Texas or Florida does not opt to expand coverage under the ACA, it will not happen. It will behoove the Obama administration and advocates of the law to actively nurture pacesetting states so that they have tangible success stories to point to in 2014 and models that other states can learn from and emulate. If even a relatively small number of states can show that uninsured people are being covered in large numbers, that federal funding is flowing as promised to the states and to individuals who qualify for insurance subsidies, that the new health insurance reforms are working as planned and that coverage is affordable and, as in Massachusetts, the public is accepting the individual mandate, then other states will take notice, whatever the ideological predispositions of their governors or legislators. It is already clear that the test in 2014 will not be whether the law is working perfectly everywhere (there isn't time for that to happen, and it won't be) but whether it can work as intended. If a handful of states can demonstrate that, then the others will want to follow. [post_title] => On Health Care, Conservatives Protest Too Much [post_excerpt] => [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => on-health-care-conservatives-protest-too-much [to_ping] => [pinged] => [post_modified] => 2014-03-04 11:14:35 [post_modified_gmt] => 2014-03-04 16:14:35 [post_content_filtered] => [post_parent] => 0 [guid] => http://kff.org/?post_type=perspective&p=71223 [menu_order] => 0 [post_type] => perspective [post_mime_type] => [comment_count] => 0 [filter] => raw ) [5] => WP_Post Object ( [ID] => 44216 [post_author] => 25629999 [post_date] => 2012-11-26 14:36:42 [post_date_gmt] => 2012-11-26 18:36:42 [post_content] => In the coming debate about the deficit, policymakers will struggle to craft a package of spending reductions and new revenues that both Democrats and Republicans can agree on, totaling as much as four trillion dollars over ten years.  Medicare, Medicaid and potentially the Affordable Care Act will have their turn on the operating table as policymakers look for savings.  It is unclear what reductions in Medicare and Medicaid spending policymakers will be able to agree on but whatever they do they will call it “entitlement reform”.   Like calling a new tax a revenue enhancement, calling spending cuts and program changes “reforms”, and even better “entitlement reforms”, makes them sound more palatable and forward thinking.  News organizations should resist mimicking labels like “entitlement reform” although understandably, policymakers and advocates will use them. The dictionary defines reform as “to improve, remove faults or abuses, habilitate, reclaim or redeem”. You can see why there would be disagreement about applying that term in the current budget debate. I was very involved in the welfare reform movement. Surely that was “reform”. Well, maybe. The essential purpose of welfare reform was to transform the welfare system from an emphasis on cash assistance to work.  Whether you were for or against welfare reform there was no question that it fundamentally changed the welfare system.  Most observers agree welfare reform has been a success and has moved welfare policy in a much better direction.  But not everyone shares that view and welfare reform has more than its share of critics.  They don’t think it is reform at all.  They see it as punitive, leading too often to low-paying jobs.  Welfare “overhaul” would have been a much more neutral description but I admit that when I was selling my welfare reform program in New Jersey and helping promote national legislation, I was more than happy to have the media call it reform. What about “health reform”? It is clear that the law makes fundamental changes to the health insurance and health care systems and will do a great deal of good, but there is obvious and sharply partisan disagreement about whether the law overall is a good thing or a bad thing.  For this reason it is the policy at NPR to avoid using the “health reform” label (and along with it the more pejorative Obamacare).  This is the practice at our Kaiser Health News as well. What then about “entitlement reform” in the context of the current budget debate?  There will be a long list of reductions in Medicare and Medicaid spending considered as this debate unfolds, from straightforward cuts such as reducing payments to hospitals and nursing homes, to changes in the rules of these two big entitlement programs such as rolling back the age of eligibility for Medicare, income relating Medicare premiums, or converting the Medicaid program to a per capita cap.  Each of these will have advocates and opponents and many of these proposals will be hotly debated.  All can appropriately be called “entitlement cuts”, or “spending reductions”, or “changes to entitlement programs”.  Some proposals - premium support for Medicare, a Medicaid block grant or per capita cap - will rise to the level of an “entitlement overhaul” or “restructuring”.  But whether a change is “reform” or good or bad will be in the eye of the beholder.  Is premium support a badly needed reform that will introduce fiscal discipline and market competition to the Medicare program as conservatives believe, or a backhanded way to cap federal spending, reduce the role of the federal government and end the Medicare entitlement, which is how many liberals view it?  Is a Medicaid block grant a way to give states more flexibility they have long wanted, or to sharply reduce federal funding to the states and eliminate the Medicaid entitlement under the guise of giving states greater flexibility?  Is raising the age of Medicare eligibility a reform whose time has come or a way to shift costs from Medicare to seniors and employers?  As we begin this new budget debate there is substantial agreement on the need to reduce spending but no agreement on what constitutes “reform” or on which “reforms” are the right ones to make. Taking an insider debate with mind numbing numbers and complex policy options and making it understandable for the American people is always a huge challenge for the news media.  That challenge will take on new importance in the upcoming budget debate.  It is understandable that policymakers and advocates would frame what they believe in or have concluded is the best budget tradeoff to make in the most positive light, but calling every spending reduction a “reform” can obfuscate the hard choices that need to be made. Let’s hope the news media will avoid loaded labels and help the public understand the consequences of different approaches to deficit reduction. [post_title] => The News Media and “Entitlement Reform” [post_excerpt] => [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => the-news-media-and-entitlement-reform [to_ping] => [pinged] => [post_modified] => 2014-03-04 11:14:36 [post_modified_gmt] => 2014-03-04 16:14:36 [post_content_filtered] => [post_parent] => 0 [guid] => http://staging.kff.alley.ws/?post_type=perspective&p=44216 [menu_order] => 0 [post_type] => perspective [post_mime_type] => [comment_count] => 0 [filter] => raw ) ) [post_count] => 6 [current_post] => -1 [in_the_loop] => [post] => WP_Post Object ( [ID] => 76279 [post_author] => 36621681 [post_date] => 2013-06-20 09:00:41 [post_date_gmt] => 2013-06-20 13:00:41 [post_content] => With the focus now mainly on exchanges, Medicaid expansions, and enrolling the uninsured in newly available coverage arrangements, there is less attention lately to the ACA insurance reforms which have always been the most popular parts of the law – changes which could affect every American’s insurance in some way and which go into effect regardless of the implementation decisions states make.  In this column, I draw on our recent tracking polls to review where the public stands on the most prominent of these insurance reforms – guaranteed issue. This is another area where information could matter because many people with pre-existing medical conditions who stand to benefit from the law don’t seem to know about it. Forty-nine percent of the American people under the age of 65 report that they or a family member have a pre-existing medical condition such as heart disease, diabetes, asthma, and cancer. Among this group, a quarter (25%) say that they or someone in their household has been denied coverage or had their premium raised because of a pre-existing condition. Thirty-five percent say they worry that they will have to pass up a job opportunity or forego retirement plans to maintain coverage and nearly one in ten (9%) say they or someone in their household has passed up a job opportunity or decided not to retire in the past year because of “job lock”. The “guaranteed issue” requirement in the ACA fixes this problem, which is called medical underwriting. It requires insurers to issue health plans to anyone in the individual or group markets, regardless of their health status, and prohibits rate surcharges based on health status in the individual and small group markets.  Like most of the ACA’s major revisions, it kicks in January 1 of next year, with open enrollment beginning this October. The provision is popular; 66% of the American people support it. It is also one of those ACA provisions Republicans like, with 56% of Republicans supporting it. The President has talked about it often, journalists have publicized it, and experts have debated the impact of eliminating medical underwriting on the costs of insurance since passage of the law.  But like many elements of Obamacare, many people who will benefit from it don’t seem to know about it. Among those who report that someone in their household has a pre-existing condition, four in ten are not aware of the guaranteed issue provision. Just like the other group who will benefit most from the ACA, the uninsured, a large number – in this case half of all people who have someone in their household with a pre-existing condition – say they don’t have enough information about the ACA to know how it will impact them or their family. Not everyone with a pre-existing condition has had a problem getting health insurance. People with employer-based coverage are protected under the previous law unless they lose their job and experience a coverage gap. Nor does liking the idea of guaranteed issue necessarily mean someone will support the ACA; people like or dislike the ACA for various reasons. And, there are tradeoffs in eliminating underwriting against people with pre-existing conditions. Premiums may rise somewhat to accommodate coverage for people who are sick (the idea is to balance this to some extent by insuring people who are young and healthy as well). But there is a large constituency of people with major illnesses who will benefit from the law who do not seem to know it, and virtually everyone benefits from the peace of mind of knowing that if they get sick they no longer can be denied coverage or priced out by surcharges, even if they have large group coverage and lose it. Right now, working people who get sick and need to leave their jobs have only expensive COBRA coverage as a temporary solution. The ACA awareness and outreach effort now getting underway is aimed more at the goal of connecting the uninsured to new coverage opportunities than helping people to understand the security of knowing that they can’t be denied coverage if they get sick. There is obvious logic in that, since the law cannot succeed without getting people enrolled. But, many people with pre-existing conditions such as cancer, heart disease, or diabetes are represented by organized and usually very effective disease groups. They have a role to play in informing their constituents about this issue as do health professionals whose patients may benefit from the guaranteed issue provision. Fifteen percent of those with a pre-existing condition say they have talked with their doctor or a medical professional about the ACA. One reason this is important now: as the economy improves, people will be looking for better job opportunities, and there is a significant group of people still afraid to change jobs because they are sick and who seem not to know that they soon will not have to worry about that anymore. ________________ (Note: In this column, I report data on pre-existing conditions from our March, April and June 2013 Kaiser Tracking Polls and our September 2011 Tracking Poll. I focus on the non-elderly because seniors are protected from medical underwriting by the Medicare program.) 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